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Guide to Wound Documentation

By Edited Jul 25, 2016 0 0

Wound documentation is extremely important in healthcare. The treatment plan and followup of a patient's injuries are compared to the baseline information originally prepared in the wound documentation by a specialist. The scope of wound documentation is wide ranging and requires as much specific information as possible. The guidelines below are an overview of the type of information expected in a well prepared wound documentation process. This list is a general guideline, but proper training is obviously required.

The essential pieces of information regarding a wound: type and location, thickness, stage (if the wound is a pressure ulcer), size, drainage, odor, wound edges, surrounding area, infection signs, and treatment. All of these items are necessary to properly prepare wound documentation. This may seem like an overwhelming amount of information, but a well trained wound professional (especially a Certified Wound Specialist) can prepare this documentation quickly and accurately in even the most stressful of situations.

Type and location - What is the nature of the wound (e.g. puncture, stab, chemical) and where is it located? This is very important since type and location can determine future treatment.

Thickness - A wound's thickness should show how far it extends into the dermis and/or epidermis.

Stage - Pressure ulcers can be documented in great detail by one of four highly specific stages or deemed unstageable.

Size - Expressed in centimeters, the wound should be measured by length and width and also depth when possible.

Drainage - The amount of discharge and the characteristics of any drainage should be noted.

Odor - Any odor if present should be described as acurately as possible.

Wound Edges - The boundaries of the wound should be described as well as the shape and it should be noted if the borders are distinct or indistinct.

Surrounding Area - Any tissue affected by the wound should be examined for redness, swelling, or other unusual characteristics.

Infection signs - A patient's symptoms should be noted if they are indicative of infections: pain, swelling, fever, discharge, warmth, etc.

Treatment - This is where the steps taken to treat and heal the wound are documented. It is also important to note any items that may prevent proper healing or treatment of the wound.

As indicated, the process of wound documentation is not learned overnight. It is a very involved procedure but a critical process in the healthcare field. The American Academy of Wound Management stresses a certain level of experience before a healthcare worker can even sit for the exam to become a Certified Wound Specialist. Those that specialize and become certified in wound documentation and treatment have many career opportunities in healthcare. Hospitals and clinics know that those workers properly trained in wound management procedures are more likely to help a patient heal faster and with less money wasted. Mastering the basics of wound documentation does take time, patience, education, practice and skill, but the quality of care that a facility is able to deliver is very dependent on it. Health workers that routinely deal with wounds are encouraged to seek more training and become board certified.



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