Wound Assessment and Documentation

chronic wound healing

By the WoundSource Editors

The stages of wound healing proceed in an organized way and follow four processes: hemostasis, inflammation, proliferation and maturation. Although the stages of wound healing are linear, wounds can progress backward or forward depending on internal and external patient conditions. The four stages of wound healing are:

Janet Wolfson's picture
the role of physical therapy in wound care

By Janet Wolfson, PT, CLWT, CWS, CLT-LANA

A story was related to me from someone living in a rural part of the US. A family member was in need of ongoing wound care. They were referred to a specialist who was of all things… a physical therapist! This is a response with which I am quite familiar. I have been referred to by a number of "titles" including Wound Coordinator, Wound Specialist, 'Skin Lady', and Wound Nurse, to name a few. If you scan my byline, I do have a good alphabet soup following my name, but to many, "PT" is a surprise.

Cheryl Carver's picture
eschar on heel pressure ulcer

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

Knowing the difference between a scab and eschar may not seem like a big deal. However, if you are being audited, or your facility is in survey, you might think otherwise. Here are a couple of scenarios for you to think about.

Rick Hall's picture
documenting wounds

By Rick Hall, BA, RN, CWON

Wound care documentation is a hot topic with overseeing agencies dealing with the medical industry. Good documentation is imperative to protect all those giving care to patients. Documentation should be Legible, Accurate, Whole, Substantiated, Unaltered, Intelligible and Timely. If these components are not incorporated into your wound care documentation, you could end up in a LAWSUIT.

Laurie Swezey's picture
Wound Assessment Tools

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

There are many tools that can be used to assess wounds. It is important to be aware of these tools and what they measure. It is also important to become knowledgeable about the tool(s) used in your workplace.

Laurie Swezey's picture
identifying infected wounds

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

As health care providers, we are all familiar with the signs of wound inflammation. However, it can sometimes be difficult to determine whether a wound is inflamed, undergoing the normal and expected inflammatory response to tissue injury, or infected. In this article we’ll review the definition of infection and assessment of the potentially infected wound.

Cheryl Carver's picture
Lab culture

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

I see it all of the time. Wound care clinicians performing wound cultures incorrectly, or obtaining cultures just because there is an open wound. With this being said, there are certain health care settings where per protocol, swab cultures are taken on every wound, even without signs and symptoms of infection. But I want you to always ask yourself a few questions when determining if a culture is warranted: Are there signs and symptoms of infection? Is there an odor after the wound has been cleansed? Has wound healing stalled? Maybe there is a biofilm present?

Cheryl Carver's picture
Staphylococcus aureus biofilm

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

One of my favorite topics to discuss in wound care is biofilms. When I conduct wound care in-services or trainings, I always ask the audience, "Who wants to tell me what a biofilm is?" There is silence. From that point, I proceed to tell my little story about biofilms. It sounds a little like this...You know when we go to bed at night, get up in the morning and feel that sticky film on our teeth? We brush our teeth with a minty-fresh toothpaste. Now our teeth feel clean. By the next morning, that sticky, fuzzy feeling returns, right? Or, when your pet's water dish develops that slimy swamp layer and then you change it? Well that, my folks, is a biofilm!

Margaret Heale's picture
Accountability

By Margaret Heale, RN, MSc, CWOCN

Most of the residents here are elderly, though some of the more acute rehab patients are quite a bit younger than me. We actually have five women over a 100 out of 116 people, quite impressive with the eldest being 105 years old. As for me, I am a retired British matron just doing a little volunteer work near where my granddaughter works.

Cheryl Carver's picture
safety net

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

Substandard documentation tops the list of mistakes for long-term care facilities. It involves "all hands in the chart" so to speak. This encompasses all disciplines, from the nursing assistant to the physician. Discrepancies and gaps in documentation put your facility at risk of litigation. Impeccable documentation is essential in defending any case. Your facility must have a "safety net" in place. This "safety net" consists of educating staff about the importance of timely and detailed documentation not only for the facility, but for their license. Often times, clinicians are not aware of the legal repercussions of their actions. Surveyors will also consider other related Federal Tags (F-Tags) during investigations for compliance.