If Wounds Could Talk
Category: Legal Nurse
Author: Georgina Tyburski
Posted: Friday - April 24, 2015
If a patient’s wound could talk in today’s health care arena… to whom would they speak? Obviously the daily responsibility for wound management is most likely undertaken by nurses … so this is where the one on one conversation begins.
To illustrate this point please be considerate of the following scenario:
Experienced and dedicated Nurse X completed a full assessment on a middle age male patient named Smitty with known history of hypertension, Type I Diabetes, kidney stones, is a one pack of cigarette smoker a day, and known to divulge in a six-pack of Guinness -Ale with his pals at the nearby local Pub daily. He presented to the outpatient wound care clinic of a major teaching hospital with a LOWER LEG WOUND ULCER.
Documentation by Nurse X included handheld bilateral lower extremity Doppler recordings with a diagnosis of an arterial ulcer resulting from vascular/arterial insufficiency. As recall has it Nurse X remembers clearly advising Smitty to cut back on his drinking and smoking with emphasis on a well-balanced diet. Completing her initial assessment was a hurried task as she was late in clocking out for her shift and needed to pick up her son from pre-school. She did verbally suggest to the attending physician a vascular consult is needed.
Inquisitively the LOWER LEG WOUND ULCER talks quite aloud reading back her initial assessment note as limited to include few words: “Advice given to patient and Doppler shows arterial with NO mention of patient’s poorly controlled diabetes noted in chart nor his need for better compliance with his suggested lifestyle changes.” Two and a half weeks later the LOWER LEG WOUND ULCER is grossly showing signs of deterioration. Why asks the LOWER LEG WOUND ULCER “Has she only documented I look LARGER with advice given and wound redressed?”
“Yes” sighs the LOWER LEG WOUND ULCER…”Smitty did make an appointment to see the Vascular Specialist/Consultant – Too late” moans the wound “As four weeks prior to this date Smitty developed a severe and painful leg infection.” Stuttering on in disbelief the wound talks feverishly “Now Smitty is admitted to the hospital and undergoes a below the knee amputation/BKA loss of limb type procedure.
As you may have suspected Smitty’s family complained to the hospital management (including their Risk Management Director) insisting the loss of his limb was due to the care received by Nurse X. The LOWER LEG WOUND ULCER overheard the family also adamant Smitty was unaware that his ongoing lifestyle of smoking, drinking and diabetes could ultimately result in a BKA/loss of limb.
Legal Nurse Consultant asks from Nurse X’s records, would you be able to defend her practice. Although in reality wounds can’t talk its clear from this scenario a thorough assessment for any wound is a prerequisite for good wound care. Also note assessment and treatment of Smitty’s pain is vital to his overall care and healing. Let the services of a Legal Nurse Consultant show you just how important record keeping is as both a professional and legal requirement…and never leaving out the essentials of accurate documentation.
