Out with the old, in with the new
Five-area comparison of wound care documents
So just how different is the new documentation at St. Peter's Home Care in Albany, NY? (See related story, p. 63.) Here's a comparison of the old wound care documentation with what is used now.
· Length.
The old document was two letter-sized pages, plus a pull-out chart. The length of new wound care documents adds up to less than a page.
Even so, the new system integrates wound care data and statements into the entire documentation package, says Carol Ann Thomas, RN, quality improvement/education coordinator at St. Peter's. She says this gives a better picture of patient care; the patient is seen as a whole, not as pieces of care.
· Objectivity.
In the old system, there was room for nurses to write their thoughts and descriptions. Indeed, most of the document's first page was given over to notations by the caregivers.
The new documentation includes spaces to check off statements and more limited space for further notes.
· Emphasis on learning and teaching.
The old documentation had no space devoted to whether or not instruction on wound care was needed. The new documents include a specific form on instruction and whether it is needed or given.
· Ease in reading.
The old documents' pull-out check charts included a large number of abbreviations at the top. Anyone reading the charts had to be intimately familiar with those abbreviations. In addition, anyone interested in a case would have to decipher the handwritten notes of the nurse.
The new forms limit the writing to be read, and the checklist format makes reading easier, says Thomas. She can tell with much less effort where a patient is in his or her treatment, and what, if anything, has been overlooked.
· Clear instructions for intervention.
The old material did not include any space to indicate intervention is needed. Rather, on the second page, there were statements that said a dietitian consultation may be appropriate if a wound is inflamed, for instance.
On the new documentation, there is a list of interventions to be checked off on the nursing assessment sheet. It is easier to determine if there is a need for additional care.
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