Documenting a Wound Assessment Properly

In any medical facility, comprehensive wound care documentation is an important aspect of day-to-day operations. It not only ensures that patients receive the high-quality treatment they deserve, but it also protects those who provide that care from lawsuits.

Sadly, lawsuits involving wound care are extremely common. One of the most efficient methods to protect yourself is to make sure that everyone who works at your institution understands how to properly document wound care.

Here are some wound care documentation examples and guidelines to ensure that your team is effectively documenting wounds:

Measure consistently
When utilizing the linear approach to document the length, width, and depth of a wound, use the body as a clock. The head is at 12:00 and the feet are at 6:00 in all cases of the linear (or clock) technique. The ruler shall be placed between 12:00 and 6:00 on the longest area of the wound for measuring length. Between 3:00 and 9:00, the width of the wound is measured at its broadest point.

Depth measurement is a little more difficult. By carefully inserting a cotton-tip applicator into the deepest section of the wound and holding the applicator up to a ruler, this can be accomplished. Tunneling and undermining can both be measured with the same applicator. Because undermining can spread in various directions, many measurements should be documented using the linear method. A nurse can characterize the undermining of the wound as “0.5 cm between 1:00 and 2:00 and 1.5 cm between 2:00 and 5:00.”

Grade appropriately
The intensity of edema, or swelling, varies depending on the patient and the lesion. Some people will have a lot of edema, while others will have very little or none. Edema can be documented using a simple but effective grading system that assigns a severity rating from one to four on a scale of one to four.

To employ this approach, healthcare workers must apply five seconds of pressure to the affected area before releasing it. The depth of the depression left determines the edema grade: grade one denotes a 2-mm depression that recovers quickly, grade two denotes a 4-mm depression that takes a few seconds to recover, grade three denotes a 6-mm depression that lasts 10 to 12 seconds, and grade four denotes an 8-mm depression that lasts 20 seconds.