How to Document Surgical Wound Classifications Properly

Surgical wound classification is the most circulated nurse document within a patient’s record once the surgical procedure is over. Since wound classifications serve as a formula to grade the extent of microbial contamination postoperatively, proper documentation of wound classifications can help to know about the possibility of developing an infection at the surgical site. This will also help to make a comparison of wound infection rates with different surgical techniques, surgeons and facilities so that you can quickly enable appropriate surveillance and take effective preventive measures. Electronic Medical Records (EMRs) specially designed for wound care can enhance the documentation further.

For accurate documentation, healthcare providers should ensure the following:

  • Thorough Knowledge about Wound Classes – Both surgeons and circulating Registered Nurses (RNs) must understand the definition of every wound class and the impact of assigning wrong wound class. The American College of Surgeons defined the wound classifications categories initially, which was later adapted by the Centers for Disease Control and Prevention (CDC) into their guidelines. According to the CDC guidelines, surgical wounds are divided into four classes such as:
    • CLASS I/CLEAN WOUNDS – Uninfected surgical wounds in which no inflammation is encountered and no respiratory, alimentary, genital, or urinary tracts are entered. These wounds are primarily closed and drained with closed drainage, if necessary. Surgical wound incisions resulting from non-penetrating trauma should be included in this class if they meet the criteria.
    • CLASS II/CLEAN-CONTAMINATED WOUNDS – Surgical wounds in which the respiratory, alimentary, genital, or urinary tracts are entered, but under controlled conditions as well as without unusual contamination. The surgical procedures that involve the billary tract, appendix, vagina, and oropharynx are specifically included in this classification if no evidence of infection is encountered and no major break in technique happens.
    • CLASS III/CONTAMINATED WOUNDS – These are open, fresh and accidental wounds. Usually, the surgical procedures in which a major break in sterile technique happens or when gross spillage from the gastrointestinal tract and the incisions in which acute, nonpurulent inflammation is encountered are included in this category.
    • CLASS IV/DIRTY OR INFECTED WOUNDS – This category includes old traumatic wounds with retained or devitalized tissue and wounds that involve existing clinical infection or perforated viscera.
  • Proper Assessment – Accurate wound class assignment is very important especially when CLASS II is the most common misused class (it should not be assigned as a default wound class when there is uncertainty and it is not a gray area between CLASS I and CLASS III wounds). Since several factors contribute to the assignment of classification such as the location of the surgery, a major break in sterile technique, the presence of existing infection at the surgical site and the presence of acute inflammation, nurses and physicians should study the wound thoroughly to document accurate details. Tools such as Surgical Wound Classification Decision Tree can be used in decision making. With a standardized wound assessment procedure, it is easy to find out these factors using appropriate tool so that the documentation of wound classification will be accurate.
  • Better Communication – Since the wound classification is subject to change, the wound class should be assigned after consulting with the surgeon at the end of the surgical procedure and should be documented in the perioperative period. So, there should be transparent and effective communication between RNs and surgeons for documenting wound classification correctly.

With EMR, nurses can document vital signs, the medicines patients take, and review symptoms and medical history using a computer in the exam room. The system will populate the appropriate data entry points automatically according to the information entered by the nurses. This will relieve them from writing and checking piles of notes in order to document wound details more accurately.

Surgeons can retrieve this information easily if their module is integrated with the module used by nurses and assess the wound class easily. The photographs of wounds can be uploaded into the EMR so that diagnosis will be easier. In short, healthcare providers can generate accurate documents regarding surgical wound classification by providing proper education to their staff about classification schema and by using efficient EMR systems.