Get Ne1 Photographic Wound Documentation - Medline Industries

How Do You Document a Wound Assessment Properly? Measure Consistently. Use the body as a clock when documenting the length, width, and depth of a wound using the linear method. ... Grade Appropriately. Edema, or swelling, can vary in severity depending on the patient and the wound. ... Get Specific.

Measure the undermining by inserting the cotton tip applicator into the area of undermining and grab the applicator at the wound edge. Measure the applicator against the ruler. When measuring undermining, use ranges. For example, if the undermining is 2 cm from 12:00 to 3:00, document it that way.

Documentation in wound care This vital information indicates the stage and progress of the wound and is vital to ensure that the next clinician caring for the patient selects an appropriate dressing.

Undermining means cutting the fibrous septae that connect the skin to the underlying fascia, and generally this is accomplished by using the scalpel to cut the septi just beneath the dermis as shown here.

Wound undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge. Undermining is measured by inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt.

Overall, documentation should record the following elements5: Wound etiology or cause (pressure, venous, arterial, surgical, etc.) Wound odor (strong, foul, pungent, etc.) Wound location, described with proper anatomical terms. Thickness characteristics for nonpressure wounds.

The location of the tunnel in the wound should be documented using the analogy of a clock face, with 12:00 pointing toward the patient's head. Undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge.

Describe the location, etiology, wound history, size, and appearance of tissue, exudate and periwound skin. Remember to incorporate any information that is relevant to potential barriers to healing such as co-factors, patient compliance issues or other complications that arise during treatment.