Proper Documentation Vital for Bite Wounds to Prevent Infection According to the Centers for Disease Control and Prevention (CDC), around 1% of all emergency healthcare visits are due to animal bites. It is also estimated that between 5% and 60% of all bite wounds can be complicated by infection. In order to prevent such infections, adequate initial evaluation and
appropriate
management
of bite wounds is
required. Accurate and comprehensive documentation helps wound care physicians understand bite wounds better
and
perform
early
wound
cleansing
and
evaluation of injured structures to ensure proper wound management. With wound-specific templates, wound EMR facilitates efficient documentation. Bite Wound Documentation There are several risk factors that lead to a higher rate of infection of bite wounds -- age (below 2 and above
50),
chronic
alcohol
consumption,
use
of
immunosuppressive drugs and so on. Wound care nurses should gather the history, wound details and other complications of the patient once they are admitted to keep a tab on these risk factors and provide appropriate treatment as soon as possible. Bite wound documentation should include:
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Patient and Wound History – Patient history includes name, age, tetanus immunization status, time delay from injury to visit, any disabilities encountered and whether any underlying immunosuppressive disease is present. Tobacco, alcohol or recreational drug use, medications and allergies should be documented as well. Wound history includes the circumstances that led to the injury, time of occurrence, location of the occurrence and whether any treatment was provided earlier.
Signs and Symptoms – You should document the signs and symptoms associated with the bite wound such as pain, fever, swelling, discharge or odor, ability to comprehend the severity of injury and cooperate with the treatment plan.
Co-morbid Conditions – It is very important to document co-morbid conditions since these may put the patient at a higher risk for infection or its sequela. These conditions include diabetes mellitus, chronic edema of the region, liver disease, and regional arterial or venous disease among others.
Wound Assessment Details – Following a thorough physical examination, nurses should assess patients’ wounds and document all details about them such as location, shape, size, type (puncture, laceration, avulsion or crush), depth of penetration, loss of tissue, tenderness, asymmetry, drainage and so on. More details may be needed for specific bite wounds (for example, loss of tissue, violation of cartilage in case of ear bites).
Wound EMR for More Effective Documentation In the case of a general EMR, wound care physicians may have to spend a lot of time to find out the wound specific details among various other types of documentation. They may mistakenly choose the wrong data or fail to provide immediate care due to the delay in finding appropriate details. As wound EMR contains templates related only to wounds, it is easier to access the required information. The outcome reporting capabilities enable to track any type of wound reports quickly. If such kind of an EMR is supported with a dedicated interface for physicians and nurses, information exchange will be much faster. Since this EMR is
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designed solely for wound care, you can easily add wound photographs and diagrams into your documentation. With a specialty wound care EMR supported on smart devices, nurses can take photographs and add them to the documentation at the bedside itself. In all ways, wound EMR outperforms general EMR and can make your bite wound documentation more effective.
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855-968-6394