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Proper Wound Documentation

Development of a pressure sore can be devastating for both the individual and his or her family. Frequently, there are questions as to how to properly treat the wound. Before an adequate treatment plan can be developed, it is important to conduct a thorough assessment of the wounds. Below is an assessment compiled by Donna Sardina, RN, MHA, WCC President, Wound Care Education Institute that appeared recently on the McKnight’s website:

Proper Wound DocumentationWhat should be included in wound documentation to support appropriate caregiving measures?

Assessment and documentation should be carried out at least weekly. The exception is when there is evidence of deterioration, in which case both the wound and the patient’s overall management must be reassessed immediately.

When wound complications or changes in wound characteristics are noted, documentation should be completed daily until the wound is stable. Documentation should include at a minimum:

Assessment findings–Type of wound, staging, correct anatomical location, measurements; presence of tunneling/undermining; drainage (amount, color, consistency, odor); wound base tissue (slough, eschar, granulation, epithelialization); wound edges (curled, callused, macerated, detached);  periwound (intact, scaly, induration, edema, redness, warmth, color).

Symptoms of infection–Fever, increased white count, hypotension, general malaise, redness, swelling, induration, streaking, purulent drainage, temperature of surrounding tissue.

Pain–Intensity, location, quality/patterns of radiation and character, duration, variations, patterns, alleviating and aggravating factors, current and past pain management plan, effects of pain, pain goal, physical exam of pain.

If a review of your family member’s medical chart does not properly address the above documentation, it is unlikely they are receiving the care necessary to heal from the pressure sore or wound.

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