Wound Healing Documentation Made Efficient with Wound Care Software

Since the wound healing process after surgery requires some time depending on the type of surgery, determining the healing status of the wound is very important for effective wound care management. In order to determine the healing status, clinicians should keep track of different healing stages and classify wounds appropriately. This is possible only if proper wound assessment is performed and the nature of the wound is documented correctly. The documentation of different healing trends can be performed easily with an EMR designed for wound care.

There are four stages for wound healing such as:

  • Hemostatis – This is the first phase in which the wound stops bleeding and starts the repair process. The injured blood vessels release fibrinogen, which causes clot formation thus stopping the bleeding. Then the body starts to break down the clot through fibrinolysis. When additional cells enter the wound bed as the clot dissolves, the next phase known as inflammation begins.
  • Inflammation – The blood vessels become more permeable and dilate during this phase and redness, swelling, warmth, and discomfort may develop around the wound bed. This phase begins within hours after the wound occurs and will remain for several days.
  • Proliferation – This phase starts approximately 3 to 6 days after the wound creation and stays for several weeks in the case of an open wound. Granulation (tissue appears as small, berry-like growths in a wound) may occur in this phase. Epithelialization or migration of cells also occurs during this phase, which begins a few hours after the wound creation. Though epithelial cells migrate across the skin from healthy wound edges, closed wound edges do not allow migration, which include rolled, calloused, or hyperkeratonic edges and may appear hard and thickened. There may be discoloration as well. At the same time, open or flat wound edges and warm, moist wound bed aids cell migration. Eschar development during the proliferation phase may necessitate the debridement of necrotic tissue.
  • Maturation – The final healing phase begins as early as seven days after the wound creation in which cell migration completes and wound contraction begins. The new tissue strengthens during this phase and it will last up to one year.

The healing phases differ based on the classification of wound healing – healing by primary intention or secondary intention. Though both healing classifications advance through the same healing phases, the rate of healing is different.

  • Primary Intention – This type of healing happens when all the tissues are surgically closed after the operation. The wound edges brought together without areas of separation or simply approximated incision heal by primary intention.
  • Secondary Intention – This type of healing happens when the wound edges are open allowing granulation tissue to develop and cover the open space. Open surgical wounds heal in this manner. The wounds that are left open intentionally and approximated surgical wounds that dehisce or separate come under this classification.

Clinicians should thoroughly study the nature of the wound to define the healing stage and classification during documentation. If they use paper-based charts, a significant amount of time may have to be spent to record all the details and access the recorded data. In order to save time, clinicians may perform the documentation in haste which can result in serious errors. For example, if nurses forget to document eschar development during the proliferation phase, physicians won’t be able to determine if debridement of necrotic tissue is necessary and it may affect healing process.

Here are the advantages of using wound EMR for wound care management.

  • The customized wound note fields help practitioners to record standardized documentation about the wound and patient along with wound measurements and wound images. This can be analyzed by the wound care specialists immediately via the physician interface and nurse interface.
  • It is easy for clinical managers to judge whether wound assessment is performed often, and track the progress. With this system outcome reports can be generated automatically based on aggregate patient data.

In this way, the healing status can be determined accurately and quickly with a reliable wound care EMR system.