Clinical decision making for wound management is dependent on the types of patients evaluated in your care settings, the skill sets of the clinicians making the decisions for those patients, the products available to manage the patient, and the documentation platform used to capture the work performed. Essentially, every step along the patient engagement continuum is strategically guided through process. In order to strategically manage your process, workflow analysis is imperative.
A workflow is a set of tasks that are completed to accomplish a goal. Your workflow should be defined with chronological processes, depicted typically through the sequential use of forms for documentation within an electronic medical record, and identified by the set of people or other resources available to perform those processes and the interactions among them. Providing this process-driven approach for yourself and to your employees can maximize the department’s efficiencies and patient throughput and ensure you have completed the necessary quality and patient safety documentation during the patient’s course of care.
It is important to analyze workflows at least annually to ensure you are capturing the proper documentation elements in the proper sequence to maximize clinical, operational, and regulatory efficiencies.
Including assessments, such as a nutrition assessment, is key to your workflow. Nutrition risk assessment tools assist the practitioner in understanding the strategies necessary to identify the levels of nutrition risk. Many nutritional components are critically important in the wound healing process. Improper nutrition can affect a patient’s immune function, collagen synthesis, and wound tensile strength, which are needed during and after the wound healing process.
Further clinical factors for wound and skin assessment include understanding the physical findings of the wound and skin, the evaluation of the patient’s laboratory values and diagnostic tests, nutrition needs, and management modalities, such as topical dressings, drugs, support surface products, and off-loading devices. Optimizing your workflow with the proper diagnostic and documentation processes is critical to these understandings.
Clinical Order Sets
Including clinical order sets in your workflow is another way to improve compliance and patient outcomes. Let’s take a closer look at the construction of clinical order sets, building upon the aforementioned nutrition assessment and the respective laboratory values necessary for evaluating nutrition.
Clinical order sets (basically, predefined templates) are one way to ensure patient safety and reduce risk. Creating order sets for the wound types seen in your department provides a common platform and support for clinical decisions related to a specific condition or medical procedure. Further, creating wound-specific laboratory values assists with the consistency of ordering and care.
Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.
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Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.