Accurate Documentation Critical for Wound Exudate Assessment

Documentation for Wound Exudate AssessmentExudate is a liquid produced by acute and chronic wounds as a result of tissue damage. Wound exudate is a natural part of the healing process as it contains nutrients, energy and growth factors for metabolizing cells and high quantities of white blood cells; cleanses the wound; maintains a moist environment and supports epithelialization. It can also reveal the problems related to the process of recovery including unhealthy inflammation and infection. Correct assessment of wound exudates is thus very important and accurate documentation of exudates via wound EMR helps in this.

Wound exudates should be assessed for color, quantity, consistency and odor as these characteristics change due to different physiologic processes and underlying complications. This will help wound care physicians analyze the complications associated with healing. For example, a rapid increase in the amount of exudates may be a sign of wound infection or ostemomyelitis. By documenting the following details of exudate properly, you can have a thorough exudate assessment.


Different types of wound exudates are as follows:

  • Serous – This is thin, clear, watery plasma found in partial-thickness wounds and venous ulceration. It is normal in the acute inflammatory stage. A moderate to heavy amount signals heavy bio-burden or chronicity from a subclinical infection.
  • Sanguineous – This refers to bloody drainage or flesh bleeding found in deep partial-thickness and full-thickness wounds during angiogenesis. If it is a small amount of sanguineous exudates in the acute inflammatory stage, then it is normal.
  • Serosanguineous – This is thin watery, pale red to pink plasma with red blood cells. They may be seen as small amounts in the acute inflammatory or acute proliferative healing phases.
  • Purulent – This is thick, opaque drainage in tan, yellow, green or brown. It is never normal and often indicates infection or high bacteria levels.


The amount of wound exudates can be expressed in the following ways:

  • None – Wound tissues are dry
  • Scant – Wound tissues are moist, but no measurable drainage
  • Small/minimal – Wound tissues are very moist or wet with drainage involving less than 25% of the dressing
  • Moderate – Wound tissues are wet with drainage covering more than 25% to 75% of the dressing
  • Large or copious – Wound tissues are filled with fluid and cover more than 75% of the dressing


  • Low viscosity – thin, runny
  • High viscosity – thick or sticky; doesn’t flow easily


  • No odor
  • Strong, foul, pungent, fecal, musty, or sweet

Wound care nurses can enter the details of wound exudates very easily with wound EMR compared to generic EMR. Wound EMR is loaded only with wound-specific templates which help nurses avoid spending too much time to find templates as with general EMR. Wound assessment templates with this system are pre-loaded with critical components of exudate assessment so that nurses can enter the specific details pertaining to the wound with much ease. Wound care physicians can access these details via the physician interface easily, perform more effective exudates assessment and ensure timely exudates management and dressing to expedite the healing process.