Home Heath

How are your clinicians documenting wound care performed?  Is it a statement, "wound care performed as ordered" or is a detailed list such as, cleansed with normal saline, applied......"   We are in Remote Client in Epic.   Appreciate your feedback as this was an area of focus during a DOH survey.  

We use Remote Client as well.  The details of the wound care are within the intervention order, the clinician selects the "performed" box, and then have them document who performed the wound care, patient tolerance, and teaching performed along with pt/cg response.  I do not feel it is necessary to re-type out the details of the wound care when they are already within the order!