Important Aspects of Wound Assessment and Documentation

Managing chronic wounds is particularly difficult, and if not done appropriately it may hinder the patient’s well being. Woundcare EHR helps physicians and other clinical staff to record the wound treatment and progress details accurately, which is an important part of wound management. Wound healing includes diverse phases such as hemostasis, inflammation, proliferation, and maturation. The most common complications of healing include dehiscence, hemorrhage, fistula, and infection. Accurate assessment skills of nurses along with appropriate interventions and accurate documentation are important to achieving optimal wound healing results.

Wound Assessment and DocumentationDocumenting assessment details correctly will help physicians to better manage the patient’s skin and wound and thus speed up the wound healing process. Proper documentation provides guidance for appropriate treatment decisions and evaluation of the healing process, which in turn supports reimbursement claims as well.

The initial assessment of any wound begins with a thorough history and physical examination. After completing the patient assessment and physical assessment, a comprehensive wound assessment is the next important step. A comprehensive wound assessment helps define the status of the wound and identify impediments to the healing process. A detailed assessment of the patient’s wound status includes wound location, size (length, width, depth), color and type of wound tissue, wound bed description, exudates, drainage amount, dressing changes needed per week, periwound skin condition, odor, adjunctive therapies and rehabilitation services offered.

Documentation should also include physician orders, initial cause of the wounds, initial evaluation, previous treatments, underlying conditions that interfere with wound healing, pain issues, medication, skin assessment, wound assessment and characteristics, treatment offered and more.

The right choice for primary and secondary dressings must be based on wound characteristics such as size, undermining or tunneling and amount of exudate. Consecutive assessment of wound is now documented using reliable wound management software. Documentation using an EMR would serve to improve patient care, increase patient safety, and simplify compliance in the U.S. healthcare system. Wound care nurses must make sure that the progress notes include patient’s progress towards achieving the desired outcomes and any unplanned assessments. Transfers and discharges must be recorded according to the facility protocol.

Photographic Documentation

Documentation with photographs helps the physician to assess the wound and measure changes over time. Digital images also solve communication difficulties between practitioners. The wound must be photographed in color on initial assessment, after wound debridement and at selected intervals, based on the clinic’s policy. An ID label should be placed alongside the wound before taking a photo. Photos can be used to document pre and post-debridement. These images can be uploaded to the patient’s EMR to show the progress of treatment to doctors, thus improving the quality of treatment. Advanced wound care software programs feature Wound Marking tool with 3D models, allowing accurate treatment and diagnosis of multiple wound sites.