NURS 403- Wound Documentation

NURS 404- Importance of Wound Documentation

Jessica Listman-Ward
May 13, 2014
Frostburg State University

NURS 403- Wound Documentation

NURS 404- Importance of Wound Documentation

As nurses we use guidelines on a daily basis. As nursing students continuing our
education we also utilize guidelines. The Essentials of Baccalaureate Education for Professional
Nursing Practice is one of the guidelines that helps prepare nursing students during their
baccalaureate career. The guidelines were created by the American Association of Colleges of
Nursing to educate nursing students and prepare them for their role as a new nurse. Each of
the courses taught at Frostburg State University utilizes the guidelines in an effort to assist
students enter their role as a baccalaureate nurse.
Importance of Wound Documentation
During this course we had the opportunity to research and improve an area of interest
related to nursing informatics. We were given the chance to create a PowerPoint presentation
on the topic chosen. The topic that I chose is one that I see on a daily basis as a medicalsurgical nurse. Every shift that I work I see patients that have some sort of wound, skin tear, or
ulcer. What I have noticed is that some of the wounds have gone undocumented for several
days. A wound that was not documented on admission is considered a wound that occurred
while the patient was in the hospital. In addition to making the unit look bad, it also reflects
poorly upon the hospital.
Utilizing the principles of nursing informatics, I created a presentation that emphasized
the importance of wound documentation. This presentation included an innovative change
that will help nurses remember to document wound and skin assessments at the time the
patient is admitted to the unit. My PowerPoint presentation was another way to use the idea

NURS 403- Wound Documentation

of informatics to help spread the word on wound documentation within the nursing field.
Nurses spend a good deal of time on the computer documenting and accessing medical
information. With that being said, presentations are often the easiest way to reach a large
population. We can add these presentations to the online learning courses that hospitals
require.
Reflection
This course and the required presentation meet Essential IV created by the American
Association of Colleges of Nursing. This essential states that
knowledge and skills in information management and patient care technology are
critical in the delivery of quality patient care (American Association of Colleges of
Nursing, 2008, p. 3).
Creating a presentation that is beneficial to patient care meets this statement. Before you can
create a presentation you must find a problem related to patient care and come up with a
solution. Next you create a presentation that will be used to initiate the change. I proposed
changing the documenting system when it comes to skin and wounds. This would require
nurses to document something instead of skipping this portion of the assessment. This would
help reduce the chance of a wound being missed on admission. Not only does this protect the
nurse and the hospital, but it provides the best quality care to the patient.
A good nurse has the ability to keep up with the changes that occur in nursing.
Technology is changing constantly. This course and this presentation help to emphasize the

NURS 403- Wound Documentation

importance of keeping up with the change. A good understanding on technology is vital for
nurses (American Association of Colleges of Nursing, 2008). If a nurse doesnt understand a
computer system, how to document, etc. then they are not able to provide proper care to the
patient. The presentation requires an understanding of the PowerPoint program. Overall, the
course and the project help illustrate the importance technology and why nurses need to
understand and be comfortable with how to utilize it.

NURS 403- Wound Documentation

Reference
American Association of Colleges of Nursing. (2008). The Essentials of Baccalaureate Education
for Professional Nursing Practice. Washington, DC: American Association of Colleges of
Nursing.