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

Nursing home resident dies after intoxicated son smothers him

A terminally ill nursing home resident died after his intoxicated son tries to suffocate him, local police say. Roy Curtis, 86, reportedly died hours after his son was arrested.

Medicare rates could be adjusted for start and end of hospice care ...

Medicare payments could be adjusted to reflect how hospice services tend to be more intensive at the beginning and end, according to findings recently published by the Centers for Medicare & Medicaid Services Office of Information Products & Data Analytics.

Medicare should pay for skilled nursing services without a qualifying hospital stay, experts tell Senators

Medicare should pay for skilled nursing services without ...

The time has come to eliminate hospital stay requirements for beneficiaries to qualify for Medicare coverage of skilled nursing services, experts told a Senate committee Wednesday.