Documentation is a form of communication that provides information about the patient or resident and confirms that care was provided. The ability to communicate a patient or resident’s condition to another healthcare provider is best done using universally accepted and understood terms, and using proper anatomical location descriptions and vocabulary is a vital part of comprehensive quality wound care. The use of appropriate terminology is essential in wound assessment and documentation.
Upon completion of the course, the learner will be able to:
- Explain the purposes of documentation
- Define the key legal terms
- Discuss essential steps in documentation
- Review documentation issues related to wound care
This course is intended for nurses.
1.0 CE for Nurses