It is not uncommon for lawsuits to arise from wound care treatment. You can provide care to the best of your ability, and sometimes poor outcomes still happen. A poor outcome does not necessarily mean medical negligence; however, when a poor outcome happens, patients can perceive that the standard of care was not provided, become unhappy, and file a lawsuit. Common allegations include delay in diagnosis, failure to properly treat, failure to timely refer, and failure to obtain informed consent. Therefore, it is of utmost importance to take measures to protect yourself and your patients during the wound care process.

Factors that Make Wound Care Challenging 
As you know, sometimes wounds can be challenging to take care of. Especially when treating patients who are diabetic, obese, have cardiovascular issues, or other comorbidities. Other factors putting patients at risk for poor outcomes are lack of support at home, poor living conditions, poor nutrition, lack of transportation, and other social determinants of health that might impact care and treatment of the patient.

Documenting Carefully for Wound Care
One of the most important things you can do is to thoroughly and accurately document your care and treatment. Here are some areas to cover in your documentation:

• History. When a patient presents with a wound, it is important to document when the patient first noticed the wound, how the wound impacts their life (wearing shoes, working, walking, etc.), any prior treatment of the wound and by whom, any other healthcare providers, including alternative/complementary providers. Document the patient’s medical, surgical, and social history. Document any medications and allergies.
• Physical Examination. After obtaining the patient’s history, document your physical findings, including the location of the wound(s), the size of the wound(s) – including length, width, and depth – as well as color of the wound, description of the wound tissue, any exudate and/or foul odor, and any other pertinent findings.
• Diagnostic Testing. Document any diagnostic testing performed or ordered and your rationale for ordering the test. What are you trying to rule out or confirm? Is the diabetic patient’s blood glucose maintained at acceptable levels?
• Patient Expectations. Determine the patient’s expectations for treatment. Are they realistic? Educate the patient about their condition, treatment options, realistic outcomes, and document all your conversations with the patient and patient education.
• Treatment. Work with the patient to develop a plan of treatment that they can adhere to. Take into consideration the patient’s current medical condition, any physical limitations, home environment (e.g., does the patient have to climb stairs to get to a bathroom or bedroom?), cost of treatment, ability to take off work, etc. Document your conversation with the patient, your plan of treatment, and your rationale for the plan of treatment.
• Follow-up. Appropriate follow-up of wounds is crucial to ensure the patient is healing as expected. Document your evaluation of the wound at each follow-up appointment, including wound size, appearance, signs and symptoms of infection, and any other pertinent findings. If the wound is not healing as expected, does the plan of treatment need to be modified? Would a biopsy be in order? Do you need to consult with the patient’s other treating physicians to coordinate care? Do you need to get the patient’s family involved to assist the patient in following the plan of care? Again, document your evaluation, whether or not the patient is healing as expected, any changes to your plan of treatment, and your rationale for changing or not changing the plan of treatment.
• Referrals. Recognize the need for a referral in a timely manner and refer the patient for additional testing or to a specialist for non-healing wounds. Timely and appropriate referrals can help prevent a poor outcome for the patient. Document all referrals, including the provider you referred the patient to, any phone conversations with the provider, and the reason for the referral. Document your conversations with the patient regarding the necessity for the referral. Also, ensure that you receive a report from the referral provider, review the report, and take any necessary actions based upon the report.

By taking these measures, you can improve patient outcomes and protect yourself from a lawsuit. Or in the event of a lawsuit, your documented care and treatment of the patient will be your best defense. 

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Disclaimer: The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. In the event any of the information presented conflicts with the terms and conditions of any policy of insurance offered by ProAssurance Insurance Company of America, the terms and conditions of the actual policy will apply. All information contained on the blog is subject to change.