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

Breier named new CEO at Kindred

Breier named new CEO at Kindred

Kindred Healthcare announced Thursday that it has chosen a new top executive to lead its push toward creating a mammoth national brand. Benjamin A. Breier, the company's current president and ...

Proposed managed care rule could accelerate shift away from nursing home care, official suggests

Proposed managed care rule could accelerate shift away ...

Proposed regulations slated for early 2015 likely will affect how Medicaid managed care balances home- versus facility-based long-term care, news sources reported Wednesday.

Assisted living residents say 'homelike' setting not so important

Contrary to conventional wisdom, assisted living residents might not place a high value on how "homelike" their surroundings are, suggest findings out of St. Catherine University in St. Paul, MN.