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

CMS expands therapy payment research

The government is expanding its research into alternative therapy payments, to consider more holistic changes to the way Medicare reimburses skilled nursing facilities, the Centers for Medicare & Medicaid Services announced Tuesday.

CDC tightens Ebola guidelines for healthcare workers

The Centers for Disease Control and Prevention has issued more stringent guidelines for how healthcare workers should interact with Ebola patients, following an outcry from nurses and other professionals.

Nonprofit providers face alarming market forces, must rally, LeadingAge chairman says

Nonprofit providers face alarming market forces, must rally, ...

Nonprofit long-term care providers must work together to address alarming trends, or their market share could plummet and the sector as a whole could falter, LeadingAge Chairman David Gehm told ...