What should be included in wound documentation?

What should be included in wound documentation?

Do describe what you see: type of wound, location, size, stage or depth, color, tissue type, exudate, erythema, condition of periwound. Don’t guess at the type or the stage of a pressure ulcer or injury (hereafter, pressure injury [PI]) or the depth of the wound.

How do you reference a wound UK?

How to cite this document: Wounds UK. Best Practice Statement: Improving holistic assessment of chronic wounds. London: Wounds UK, 2018.

What are the 5 rules of wound care?

In this article, the authors offer five generalisable principles that colleagues providing community care can apply in order to achieve timely wound healing: (1) assessment and exclusion of disease processes; (2) wound cleansing; (3) timely dressing change; (4) appropriate (dressing choice; and (5) considered …

How do you write a wound Report?

10 Steps for Writing a Wound Care Case Report

1. Talk to Colleagues:
2. Conduct Research:
3. Seek Permission:
4. Compile the Patient Background and History:
5. Document Wound Assessment:
6. Describe Treatment Protocol:
7. Document Results:
8. Include Photo Documentation and Clinical Data:

How do you document the size of a wound?

The wound is typically measured first by its length, then by width, and finally by depth. The length is always from the patient’s head to the toe. The width is always from the lateral positions on the patient. The depth is usually measured by inserting a q–tip in the deepest part of the wound with the tip of finger.

How do you describe a wound in writing?

Use correct terminology to describe your findings, such as ecchymosed (bruised), erythematous (red), indurated (firm), edematous (swollen). Wound edges must also be carefully defined. Wound edges can be described as diffuse, well defined or rolled.

How do you chart a wound assessment?

How Do You Document a Wound Assessment Properly?

1. Measure Consistently. Use the body as a clock when documenting the length, width, and depth of a wound using the linear method.
2. Grade Appropriately. Edema, or swelling, can vary in severity depending on the patient and the wound.
3. Get Specific.

What factors need considering when photographing wounds?

Always consider the patient’s dignity when taking a photograph. It is important to cover genitals if they are slightly exposed, or the anus if the wound is on the sacrum. Should the patient be inconti- nent, it is important to ensure they are fully clean before taking a photograph.

How do you perform a wound assessment?

Seven key steps

1. Step 1: Health history. Keep the patient’s clinical status in mind when performing a wound assessment.
2. Step 2: Location and type of wound. Location may be challenging at times to discern.
3. Step 3: Dimensions.
4. Step 4: Tissue type.
5. Step 5: Odor.
6. Step 6: Drainage.
7. Step 7: Periwound skin.

What are the 3 principles of wound management?

The basic principles for the management of a wound or laceration are:

• Haemostasis.
• Cleaning the wound.
• Analgesia.
• Skin closure.
• Dressing and follow-up advice.

How do you document the edge of a wound?

How do you measure a document wound?

How to document wound?

Method 2 of 2: Measuring with Tracing Obtain 2 wound tracing sheets and clean one of them. You’ll need 2 different types of sheets. Place the transparency over the wound and trace the wound. Make sure that the transparency covers the entire wound. Label the adhesive tracing with the patient’s information and wound size. Decide how frequently to measure the wound.

What is wound care assessment?

Wound assessment. Wound assessment is a component of wound management. As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, that may be relevant to planning and implementing the treatment.

What is a nursing documentation?

Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process.