Wound Assessment and Documentation

Martin Vera's picture
wound healing

By Martin D. Vera, LVN, CWS

It is no surprise to coworkers, colleagues and even my patients that I am a huge advocate for education and of course, the building of a strong foundation. My personal experience has been that after I had built that strong foundation—as in, understanding the skin and cells involved in each layer, wound bed preparation framework and the phases of wound healing with the key cells involved in each phase—I became more efficient, provided better services and improved positive outcomes for my patients. And once the types of wounds came along, I felt prepared and ahead of the game to accept the challenges and complexities of each wound type, and educated myself to know the differences. As a clinician driven by a passion for healing patients, I can’t help but look for ways for me to improve and further educate myself, as well as bring others on board to join me and the thousands of clinicians out there gathered to fight for a good cause.

Terri Kolenich's picture
long-term care facility pressure injury staging at admission

By Terri Kolenich, RN, CWCA, AAPWCA

Question: What are Quality Measures, how does my long-term care facility measure up, and how can we improve?

WoundSource Editors's picture
signs of wound infection

A break in the skin through injury or surgery creates an open entry for bacteria to enter the body and begin to multiply. Recognizing the first signs of wound infection enables health care professionals to intervene with treatment swiftly. Here are some of the most common signs and symptoms associated with a wound infection:

Martin Vera's picture
wound healing and wound bed preparation

By Martin D. Vera, LVN, CWS

Wound bed preparation has become the gold standard model for proper wound assessment. It allows us clinicians to identify and breakdown local barriers to wound healing. Throughout our health care careers, we have seen it over and over again: the collective emphasis on standards of care, evidence-based practice, and cost-effectiveness in order to achieve positive outcomes for our patients.The wound bed preparation model supports all of these aspects of care delivery.

Catherine Milne's picture
do the right thing

By Catherine T. Milne, APRN, MSN, BC-ANP, CWOCN-AP

From Nike's "Just Do It" ad campaign to Google's corporate "Don't be evil" code, I've always been struck by the many marketing campaigns that remind us to pay attention to our conscience. A similar focus should apply to health care. In 2000, the Institute of Medicine (IOM) published a scathing report showing that the number of people who died from medical errors surpassed the combined total of those who died from breast cancer and car accidents.1 To make matters worse, this was likely a low estimate. In 2013, the Journal of Patient Safety reported that adverse events from preventable harm may affect between 210,000 and 440,000 hospital patients each year.2 As clinicians, we've all taken an oath, a pledge or a vow to "do no harm." Why is the reality so far from the ideal?

Cheryl Carver's picture
Stage 1 Pressure Injury - Darkly Pigmented Skin


I have worked all over the country as an educator. The same gaps in education arise everywhere. A few years ago, I began teaching skin color awareness as part of my course curriculum. I feel strongly about it being a part of my inservices and course education. Understanding skin color as it relates to assessment is critical in the prevention of pressure injuries.

Lindsay Andronaco's picture
surgical wound bandage and drainage

By Lindsay D. Andronaco RN, BSN, CWCN, WOC, DAPWCA, FAACWS

Wound exudate and how to properly assess and manage it has been a long standing clinical challenge in wound care. Assessing the exudate color, odor, volume, viscosity, and if it is causing maceration of the periwound skin are all important to note when creating a care plan for the patient. If there is not proper management of the exudate, then the high protease levels and low growth factor levels will negatively impact wound healing time.

Temple University School of Podiatric Medicine's picture
WoundSource journal club blog

Temple University School of Podiatric Medicine Journal Review Club

Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Mary Ellen Posthauer's picture
health care quality measures

By Mary Ellen Posthauer RDN, CD, LD, FAND

The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT) amends Title XVIII of the Social Security Act by adding a new section –Standardized Post-Acute Care (PAC) Assessment Data for Quality, Payment, and Discharge Planning. The goal of the IMPACT Act is to reform PAC payments and reimbursement while ensuring continued beneficiary access to the most appropriate setting of care. The act requires the submission of standardized and interoperable PAC assessment and quality measurement data by Long-Term Care Hospitals (LTCH), Skilled Nursing Facilities (SNF), Home Health Agencies (HHA) and Inpatient Rehabilitation Facilities (IRF).

Cheryl Carver's picture
patient repositioning for pressure injury prevention


I am very passionate about wound care, but pressure injury (pressure ulcer) prevention and awareness is at the top of my list for many reasons. My mother passed away in my arms at the young age of 47 due to complications of diabetes, amputation, and three pressure injuries. My mother's hospital-acquired pressure injuries were avoidable.