Think like a Surveyor, Act Like a Wound Nurse, Pt. II: LTC Wound Documentation

Last month, I got on my soapbox about advanced wound care assessment. This month, I want to continue the theme by discussing the need to make complete and accurate wound documentation a priority, especially in the long-term care (LTC) setting.

LTC is the most regulated and penalized healthcare setting. The Omnibus Budget Reconciliation Act (OBRA ’87)—specifically F-tag 314 and Balanced Budget Act (BBA ’97)—increased the regulations especially for nursing care in LTC. F-tag 314 expanded surveyor authority regarding pressure ulcers, as well as directing them to review other F-tags while investigating compliance.

Advanced wound care LTC documentation

My last blog started the topic with “think like a surveyor, act like a wound nurse.” This month, I want to underscore the importance of “writing like a surveyor” when documenting. Although I want to focus on wound documentation, I need to mention that risk assessment (for pressure ulcers in particular) and prevention planning (with documentation) are parts of any survey. Documentation of “unavoidable ulcers” is a huge challenge for LTC and requires meticulous charting to show the facility did everything possible to prevent the ulcer, that the ulcer developed, and that the care plan was adjusted. Reimbursement can be lost and fines applied if the “unavoidable” documentation does not meet documentation requirements.

Wound documentation should include all the assessment points made in last month’s installment. “Think like a nurse” and focus on the whole patient—rather than exclusively on hole in the patient. Although pressure ulcers are a main focus, dermatitis due to incontinence, venous, arterial and diabetic ulcers are also issues and should be managed proactively to prevent additional challenges and possible fines.

Along with assessing and documenting interventions—and their outcome(s)—the sample applies to changes in the care plan when those interventions are not having the desired effect. Interventions do not relate to the topical treatments (e.g., dressings and cleansing), but also to interventions that mitigate the underlying disease processes. Examples include:

  • Pressure redistribution and turning for pressure ulcers

  • Compression for venous insufficiency

  • Monitoring of blood sugar for diabetes

Additionally, here are some F-Tag 314 special documentation points to consider:

  • Be sure the wound is diagnosed correctly and documented as the correct type (e.g., pressure, venous and arterial).

  • It is not sufficient to just document the stage of a pressure ulcer. A description of the ulcer, treatment, pain and progression/deterioration is required.

  • The physician must be notified of changes. Facilities can be cited for not involving the MD, not documenting MD supervision in treatment, failing to use the correct products and/or not notifying the facility medical director.

According to the ProPublica database, failure to develop a comprehensive care plan and clinical records that don’t meet professional standards were two of the top 10 most commonly violated regulations in 2012. Attention to wound assessment and documentation detail (and knowing the requirements) can help LTC facilities avoid costly citations.

Additional Resources

  • Consider accessing resources such as to view documents or find a CWOCN in your area.

  • Wound education online (free and minimal cost) is available from many companies and journals (such as WOCN’s Advances in Wound Care and Ostomy and Wound Management).

  • Books such as Skin and Wound Care by Cathy Thomas Hess or Chronic Wound Care by Diane Krasner (both available on Amazon).


Please be sure and comment on any experiences and expertise you have on this topic. My next installment will be on “Topical Interventions” and how to take some of the confusion out of choosing the right product for the right wound (patient) at the right time.

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