Ask the treatment expert

Share this article:
Ask the treatment expert
Ask the treatment expert
What are some guidelines we can follow for documenting incision-site care in fresh post-op residents?

• Mark time since surgery in days.  Example: Postop day 6

• Document the anatomic location of the incision.

• Chart the length of the incision in centimeters and include the depth measurement whenever appropriate. 

• Indicate the type and number of materials used to keep the incision closed: sutures, staples or clips, retention sutures, or tape closure. 

• Describe the appearance of the incision and surrounding skin. 
 
• Indicate presence or absence of epithelial resurfacing. “The incision is well approximated and there is complete epithelialization of incision.”

• Provide detailed information if complications are noted. Include when the complication occurred, who was notified, the interventions ordered and provided, and the resident's response to those interventions. 

• Document if signs of infection are present: redness, swelling, purulent drainage, tenderness or warmth.

• Assess and record a residents pain levels using a pain intensity scale. 

• Dressing Changes

*  Assess pain prior to, during and after all dressing changes.

*  Record the appearance of any drainage on the dressing and indicate the amount of dressing saturation.

*  Indicate how you cleaned the incision and what type of dressings were used.
*  Document the resident's response to the dressing change.

• Intact Dressing

*  Evaluate the status of the dressing (whether it is intact, if drainage is noted and if it is leaking).

*  The status of the area surrounding the incision (that can be observed without removing the dressing).
Share this article:
close

Next Article in News

More in News

A small team of workers responds best in emergencies, expert says

A small team of workers responds best in ...

Long-term care providers should consider a "flat" crisis management approach that relies on a core group of staff members, experts advised Wednesday at the LeadingAge annual conference.

Nursing homes have better pain and catheter management if leaders have more ...

Nursing homes led by administrators and directors of nursing with higher levels of education and certification have better outcomes on some key quality measures, according to recently published findings.

Court green-lights charges that a healthcare network underused observation stays

A whistleblower can continue to pursue charges that a Nevada healthcare network routinely admitted people as hospital inpatients when they should have been placed in observation status, a federal appeals court recently ruled.