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What should be included in wound documentation to support appropriate caregiving measures?

Assessment and documentation should be carried out at least weekly. The exception is when there is evidence of deterioration, in which case both the wound and the patient's overall management must be reassessed immediately.

When wound complications or changes in wound characteristics are noted, documentation should be completed daily until the wound is stable. Documentation should include at a minimum:

Assessment findings–Type of wound, staging, correct anatomical location, measurements; presence of tunneling/undermining; drainage (amount, color, consistency, odor); wound base tissue (slough, eschar, granulation, epithelialization); wound edges (curled, callused, macerated, detached);  periwound (intact, scaly, induration, edema, redness, warmth, color).

Symptoms of infection–Fever, increased white count, hypotension, general malaise, redness, swelling, induration, streaking, purulent drainage, temperature of surrounding tissue.

Pain–Intensity, location, quality/patterns of radiation and character, duration, variations, patterns, alleviating and aggravating factors, current and past pain management plan, effects of pain, pain goal, physical exam of pain.

Next month: Learn about seven more areas that require strong wound documentation practices.
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