How to Care for Open Wounds

Open WoundsOpen wounds are often a life-threatening condition in trauma patients. Soft tissue infection and sepsis were the most feared complications in patients with trauma. In open wounds, the skin is cracked open, leaving the underlying tissue exposed to the outside environment, which makes it more vulnerable to bleeding and infections. These wounds are often classified depending on their cause and include abrasion caused by rubbing the skin against a hard surface, laceration that is a deep cut or tearing of the skin, and puncture, a piercing wound that causes a small hole in the tissues. Proper wound care requires accurate and complete documentation that also helps wound clinics to enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care.

To heal the open wounds faster, it is crucial to:

  • Keep them clean and moist
  • Control the bleeding by using direct pressure
  • Change the wound dressing at least once daily

Before applying a sterile dressing, all particles or debris should be removed to prevent infection or scarring. After cleaning and possibly numbing the area with anesthetic, your doctor may close the wound using skin glue, sutures, or stitches. For a small wound that does not require sutures, it is recommended to cover it with a thin layer of antibiotic ointment such as Polysporin or Bacitracin, or with a sterile dressing.

The major complication of an open wound is the risk of infection. Signs of infection include continuous bleeding and an increase in redness, pain, swelling, inflammation, loss of function and scarring.

Open Wound Documentation with EMR

Open wound documentation must include type of wound with size, depth, and length in centimeters, description of wound bed appearance, drainage (odor, color), skin condition, pain associated with the wound, progress(improved, no change, stable or declined) and specific interventions ordered by the physician.

Proper documentation with wound specific EMR helps in guiding treatment decisions and thus ensuring improved patient care. Wound assessment reports can be entered into the system for future reference.

Wound care templates in the software make documentation much easier. Wound EMR templates help to eliminate handwritten wound charting and thus accurately track wound progress, reducing citations. This advanced software also features both nurses’ module and physician module, which makes it easy for the healthcare team to document their findings and treatment. Digital images of wounds can also be uploaded, resulting in accurate assessment and diagnosis.