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.

Client Reviews

★★★★★
Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
★★★★★
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric