Ask the treatment expert: What are some of the documentation things nurses often miss?

Share this article:
Susan Wickard, RN, BSN, CWCN, CWS, CLNC
Susan Wickard, RN, BSN, CWCN, CWS, CLNC

What are some of the documentation things nurses often miss?

A useful resource, “Wound Care Made Incredibly Visual,” offers an acronym that may be helpful in highlighting information that should be included when documenting about wounds: 

WOUNDD PICTURE

Wound or ulcer location

Odor (in room or just when wound is uncovered)

Ulcer category, stage (for pressure ulcer or classification for diabetic ulcer) and depth (partial thickness or full thickness)

Necrotic tissue

Dimension (shape, length, width and depth)

Drainage color, consistency, and amount (scant, moderate or large)

Pain (when it occurs, what relieves it; patient's description; and patient's rating on scale of 0 to 10)

Induration (hard or soft surrounding tissue)

Color of wound bed (red, yellow, black or combination)

Tunneling (length and direction — toward the patient's right, left, head, or feet)

Undermining (record length and direction, using clock references to describe)

Redness or other discoloration in surrounding skin

Edge of skin loose or tightly adhered and flat or rolled under

When documenting on the wound itself, it is important to record the date and time the assessment was made. The initial documentation should include a narrative note. Correct anatomical terms should always be used.

Regardless of assessment format or style, just make sure good, complete documentation about the wound is done.

Also, make sure you follow your facility protocol on wound documentation. 


Share this article:
close

Next Article in News

More in News

Also in the news for Sept. 22, 2014

ER support program can reduce hospital admissions among seniors, study says ... Researchers find defect that may lead to Alzheimer's ... Technical glitch may cause milions in payment delays for physicians who adopted EHRs

Enterovirus hits KY nursing home

Nine residents at the Heritage Hall nursing home are confirmed to have a strain of enterovirus, according to local reports.

AHCA applauds Senate passage of IMPACT Act

The Senate approved the Improving Medicare Post-Acute Care Transformation Act, drawing praise from the American Health Care Association and the National Association for the Support of Long Term Care.