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
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):

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.

Aletha Tippett MD's picture

By Aletha Tippett MD

We are supposed to check a wound every week and measure length, width and depth. These measurements should be getting smaller if the wound is healing, and we need to see improvement within two weeks, or have to consider that we need a different dressing on the wound. Of course, we also look at the type of tissue in the wound - granulation, slough, or necrosis - and the amount of drainage and odor. Those things can change our opinion about the wound. Maybe the wound measurements are not smaller but the wound has good granulation and shows signs of contraction - that wound is healing despite the measurements. Wound measurements can be very inaccurate. Often it depends on how the patient is positioned and who is doing the measurement. Even the same person taking measurements will not be the same every time.

Karen Zulkowski's picture

By Karen Zulkowski DNS, RN, CWS

Documenting wounds is always problematic for staff. It is important that wounds be assessed consistently both for measurement and characteristics. The use of pictures is also controversial. Pictures can help or hurt you if you are sued. However, consistent documentation of the wound, treatment and care planning that accompanies a picture would be useful.

Laurie Swezey's picture

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

Arterial ulcers can cause much pain for patients and consternation for the wound care professionals tasked with managing them. Arterial ulcers can be a catch-22 in that many patients with arterial ulcers present with edema, but due to the nature of their problem cannot be safely compressed.