Wound care and nursing records

Keep wound, catheter, PEG and pressure care records up to date, and sign off clinical reviews.

Before you begin

• Your role can view health records; assessments need the assess permission (nurses by default).
• The wound, catheter or feeding regime is already on the record.

Open the clinical tab

1. Go to Care → Health and high-intensity, choose the participant and open PEG, catheter and wounds.
2. The page shows three cards: PEG and enteral feeding, Catheter and continence care and Wound and pressure care, plus Participants with clinical supports listing everyone with open wounds or catheters.

Record a wound assessment

1. In Wound and pressure care, find the open wound and select New assessment (nurses and clinicians with assess permission).
2. Fill in Stage, Size (for example 2 x 3 cm), Trend (Improving, Stable or Deteriorating), Next dressing, Dressing plan and Notes.
3. Select Save assessment. A deteriorating trend alerts the RN on call.
4. Overdue dressings count in Overdue care (dressings, catheter) at the top of the page.

Record a catheter change or output

1. In Catheter and continence care, select Record change after a change. The message gives the next change date.
2. Select Record output to add a catheter output chart entry (Volume (mL) and Colour).
3. Next change due turns amber within 3 days and shows days overdue after the date.

PEG feeds and pressure care

1. The PEG card shows Formula, Rate, Schedule, Flushes and Stoma care from the feeding regime, and recent feeds.
2. Select Record feed to add an enteral feed entry (Volume (mL), Flush (mL)).
3. The pressure care banner shows the repositioning interval and when the person was last repositioned.

Nurse sign-off

1. On Alerts and oversight, a nurse selects Start review for the person, then Sign off with a Clinical note and Actions (one per line). Signing off resolves the linked alerts.

Tips

• Use the Notes field on an assessment for anything that does not fit the other fields.

If something goes wrong

New assessment is missing.

It needs the health assess permission, held by registered nurses by default.

“… does not have a catheter” shows, or no wound is listed.

Catheters and wounds are added to the record first. Ask the nurse.

Sign-off asks you to confirm your identity.

Clinical sign-off needs a recent sign-in check. Complete it and try again.