Wound Assessment and Documentation

Mary Ellen Posthauer's picture
medical records

By Mary Ellen Posthauer RDN, CD, LD, FAND

As Dr. Aletha Tippett noted in her December blog, following wound documentation standards can help clinicians avoid legal issues. Pressure ulcer litigation often involves pressure ulcers and weight loss.

WoundSource Editors's picture

By the WoundSource Editors

Writing up a case report is an important professional activity in not only wound care, but in any other field as well. A case report records the details of the presentation of signs and symptoms, assessment, diagnosis, treatment and outcomes of a patient case or series of cases. Case reports typically describe an unusual presentation or complication relating to the patient's condition, or a new clinical approach to a common problem. The publication of a case report in a peer-reviewed journal, if that is your intent, is a great addition to your CV, especially if you are new to the profession.

WoundSource Editors's picture
Image from the National Cancer Institute

By the WoundSource Editors

A myriad of factors need to be addressed when evaluating a patient with a wound. A thorough patient history, including previous wounds, surgeries, hospitalizations, and past and existing conditions will help guide your clinical assessment, in addition to a number of questions specific to the wound(s) being assessed. Following is a list of general questions to ask when evaluating a wound care patient. (Please note that this list is not comprehensive and is intended only to serve as a guide):

Cheryl Carver's picture
band aid treats

By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

It is getting close to Halloween! Halloween is one of my favorite holidays, so lets have some fun with the serious subject of long-term care facility state surveys, which can occur regardless of the holidays...

Bruce Ruben's picture

By Bruce E. Ruben MD

This particular blog is not necessarily intended to educate, but to be a thinking piece that asks more questions than it answers.

Janis Harrison's picture

By Janis E. Harrison, RN, BSN, CWOCN, CFCN

As I was pushed from the room where my husband was coding, I was met by a tiny little nun, we'll call Sister. She tried to move me to a waiting area nearby but I knew I was not going to step away from the door. They had not listened to or assessed my husband during a very concerning time and he was supposed to be in post-op recovery.

Laurie Swezey's picture
Tunneling Wound

By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

As part of a thorough wound assessment, in addition to noting location and measuring size, the entire wound bed should be probed for the presence of tunneling and/or undermining. If you are unsure what tunneling and undermining are and how to recognize these phenomena, here's an explanation of these terms and how to assess wounds for their presence.

Janis Harrison's picture

By Janis E. Harrison, RN, BSN, CWOCN, CFCN

My husband Daryl had gone in to a same-day surgery center for incisional hernia repair and possible "tummy tuck" after losing 85 pounds. We had searched for a good surgeon and opinions on any complications that might need to be considered, since Daryl had an ileostomy. We discussed whether or not mesh should be used, infection possibilities, and if he should have the skin tucked that was now loose from weight loss. One surgeon was not sure he wanted to tackle the task and possible complications. Another surgeon just said "sure, I can do that." Well, of course we wanted a competent surgeon; one with confidence and a little arrogance, but then, this was just a "simple" incisional hernia repair, right? WRONG!

Laurie Swezey's picture

By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

Wound care diagnostics includes examination of wounds for the purpose of wound classification. Why does it matter? It matters because treatment varies greatly depending on the type of wound. For example, venous insufficiency ulcers are treated differently than arterial insufficiency ulcers. Failing to differentiate between these wounds could mean the loss of a limb. Let’s take a look at some of the commonly used diagnostics in wound care.

Laurie Swezey's picture

By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

The measurement of a wound, and the plotting of its size over time, is the only estimate that can be used to accurately predict wound healing. This includes such variables as wound exudate, the presence of necrotic tissue, slough and granulation tissue, as well as undermining and tunneling.