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Wound Care Documentation Across the Multidisciplinary Team

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1.  Why is the stellar documentation of wound care interventions by therapists essential? Wounds constantly change It is necessary for legal purposes It provides a description of client care, focusing on completed tasks and interventions All of the above

2.  An example of client-centered wound care is: The treatment for a client’s wound is reactive rather than proactive The physical, emotional, social, and cultural needs of a client are central in creating their plan of care The only treatment goal is to close the client’s wound All of the above

3.  What are the “three C’s” of documentation? Consistent, Comfort, Coordination Congruent, Conglomerate, Collaboration Collaboration, Coordination, Communication Conclusive, Consistent, Coordination

4.  What reason(s) are often cited upon medical review as not being documented appropriately to support medical necessity and justify the services billed? Reason for Referral Goals Skilled interventions All of the above

5.  What can interfere with effective communication between the multidisciplinary team? Nursing and therapy agreeing on a consistent method of communication regarding clients with wounds Lack of respect for other disciplines Understanding and accepting personal, cultural, and professional differences of members of the multidisciplinary team All of the above

6.  When using a modality as part of the wound care intervention, the clinician should document: Positioning of the client Parameters of the modality The client’s tolerance to treatment All of the above

7.  When assessing a wound, ___________should be included as part of the assessment. Quantity and quality of exudate Respiration rate Glomerular filtration rate All of the above

8.  To support therapy’s involvement prior to initiating services, nursing documentation should: Include a breakdown of the client’s daily schedule Include direct verbiage from state practice acts Support prior level of function and the need for therapy All of the above

9.  Effective communication between nursing and therapy includes: Respecting each discipline’s contribution to client centered care Negative stereotypes of each discipline Questioning a provider’s competence All of the above

10.  When documenting for a client living with a wound, the prior level of function should include: A list of diagnosis codes How the client was functioning just prior to the onset/exacerbation of the wound Long term goals for the client All of the above