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Wound Management Policy and Procedure Manual

Wound Management Policy and Procedure Manual

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Wound Management Policy and Procedure Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.
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Changes Table of Contents - TJC standards Copyright Disclaimer Approval/Signature Sheet Introduction

SECTION I - ETHICS, RIGHTS AND RESPONSIBILITIES

Patient Rights and Responsibilities Informed Consent Photographing/Videotaping Patients Authorization and Consent Form - Photograph and Publication Advance Directives Patient Grievance Process Confidentiality of Information - General Issues Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/ Exploitation Conduct of Clinical Trials/Research Projects

SECTION II - PROVISION OF CARE, TREATMENT AND SERVICES

Admission and Assessment

Initial Patient Assessment and Reassessment Admission Assessment Form Skin Assessment Wound Assessment and Reassessment Wound Measurements Pressure Ulcer Assessment Form - Sample Clinical Staging of Osteomyelitis Ankle Brachial Index (ABI) Nutritional Screening/Monitoring Patient Nutritional Levels - Definition Nutritional Assessment Rationale and Purpose Nutritional Assessment of Patients by the Registered Dietitian Nutritional Consults Nutritional Assessment and Support Overview Flowchart Nutritional Assessment Guide for Patients with Pressure Ulcers - Sample Form Fall Prevention Assessment of Adult Patient/Resident at Risk for Falls Form Pain Assessment, Reassessment and Management Pain Scale Examples Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients Pain Management in Wound Care Care of the Latex Sensitive Patient Latex Allergy Assessment Form Latex and Non-Latex Alternatives

Patient Care Procedures

Care Planning Patient Identification for Clinical Care and Treatment "Hand-Off" Communication Bed with a Cradle Diabetic Neuropathic Foot Ulcers Monofilament Test Vibratory Test Dressing Change - Surgical Dressing Change - Wet-to-Dry The Dying Patient - Care of End of Life Issues Enzymatic Debridement Emergency Wound Management Eggcrate Mattress Use Invasive Procedure Site Identification Logrolling Management of Pressure Ulcers Management of Pressure Ulcers: Overview Flowchart Managing Bacterial Colonization and Infection Flowchart Ulcer Care: Overview Flowchart Pressure Ulcer Prevention Program Positioning Guidelines Management of Urine/Fecal Incontinence Pulse - Femoral Pulse - Pedal Pulse, Dorsalis Pedis and Posterior Tibialis Pulse - Popliteal Postoperative Ostomy Care Ostomy Care - Changing the Pouching System Pulsed Lavage Removing Tape from a Patient's Skin Skin Tears Turning and Repositioning of the Immobile Patient Transparent Film Dressings Support Surfaces Management of Tissue Loads Flowchart Wound Dressings - Selection and Types Use of Clinical Alarms on Medical Equipment Arterial Ulcers Venous Ulcers Whirlpool Debridement (Hydrotherapy) Whirlpool Area Safety Whirlpool Cleaning Wound Cleaning Wound Cultures

Patient and Family Education

Education of Patient and Family Instructions for Home Care Form Patient and Family Education - Ostomy Care

Discharge or Transfer

Discharge Planning Patient Transfer and Referral Record Form

SECTION III - MEDICATION MANAGEMENT

Controlled Drug Management on Patient Care Units Automated Dispensing Machines - Controlled Substances Narcotics Decreasing Medication Errors Emergency Crash Carts Prescribing/Ordering - General Practices Medication Ordered STAT and at Specified Time Intervals Automatic Stop Orders Range Orders for Medications Pediatric Dosing - General Guidelines Telephone, Verbal and Written Orders for Medication Safe Medication Practices Medication Reconciliation/Verification Medication Reconciliation/Verification Form Medication Administration Medication Administration to Pediatric Patients Automated Dispensing Machines - Removing Medications Tetanus Prophylaxis Medication Errors Adverse Drug Reaction Reporting Form Potential Adverse Drug Reaction Form Medication Inadvertent Incident Report Medication Inadvertent Incident Report Form

SECTION IV - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION

Infection Control CDC Criteria for Defining a Surgical Site Infection (SSI)Hand Hygiene - CDC Guidelines Standard Precautions Asepsis Transmission-Based Precautions (Isolation Precautions)Sharps Injury Protection Plan Sharps Injury Log Form Handling of Biohazardous Waste

SECTION V - IMPROVING ORGANIZATION PERFORMANCE

Performance Measures/Outcomes Patient Care Unit/Wound Management Program - PI Monitoring and Evaluation Plan Patient Care Unit/Wound Management Program - PI Trending Sheet Patient Care Unit/Wound Management Program - PI Outcome Evaluation Patient Care Unit/Wound Management Program - PI Volume Measures/Statistics Performance Improvement Department - Notification Form Sentinel Event Incident Reporting Staff Questionnaire Form

SECTION VI - LEADERSHIP

Development of Departmental Policies and Procedures Development of Interdepartmental Policies and Procedures Standing Orders

SECTION VII - MANAGEMENT OF ENVIRONMENT OF CARE

Safety Body Mechanics - Staff Education Handout Electrical Safety Use of Electrical Equipment in Oxygen Enriched Environment Violence Management Recognizing Inappropriate Behavior Conduct to Minimize Violence Hazardous Materials and Waste - Nursing Services Hazardous Materials and Waste - Training How to Read Safety Data Sheets (SDS)Chemical Training Record Form Compressed Gas and Oxygen Use Emergency Management Fire Safety Types of Fire Extinguishers Reporting Equipment Malfunction

SECTION VIII - MANAGEMENT OF HUMAN RESOURCES

Position Description/Performance Evaluation - Wound Care RN Performance Evaluation - Population-Specific/Age-Related Competency - Wound Care RN Annual Competency Clinical Skills Assessment - Wound Care RN New Hire Policy New Employee Orientation Organizational Personnel Education Plan Staff Qualifications and Competency BCLS/ACLS Resuscitation Certification

SECTION IX - MANAGEMENT OF INFORMATION

Documentation Legibility of Medical Record Documentation Unacceptable Abbreviation and Symbol List Acceptable Abbreviations List Use of Summary List Sample Summary List Verbal and Written Orders - General Acknowledgment of Results of Diagnostic Testing Critical Tests and Result Reporting