Here are a few wound care documentation samples and tips to ensure your team is documenting wounds effectively: 1. Measure Consistently Use the body as a clock when documenting the length, width, and depth of a wound using the linear method.
Full Answer
How to properly document a wound?
How to Properly Document a Wound WoundSource. Woundsource.com DA: 19 PA: 44 MOZ Rank: 64. Choose language such as "filled the wound loosely," or "laid the dressing in the wound bed" to document your wound treatment; When measuring a wound, measure from head to toe for length (0600 and 1200), and 0300 to 0900 for width
What are the best tips for a wound care nurse?
Wound Care 101
- Assessment basics. Successful wound management starts with a thorough assessment of the wound and periwound skin. ...
- Identifying wound etiology. ...
- Topical therapy: Eight key objectives. ...
- Look at the whole picture. ...
- Follow key principles and guidelines. ...
- Key resources. ...
How to document scab wound?
Document Wound Exudate (Drainage) Document Wound Odor . Document Method of Debridement + Document Drainage Type Serous – thin, watery, clear . Sanguineous – thin, bright red, fresh bleeding Serosanguinous – thin, watery, pale -red to pink Purulent – thick or thin, opaque -tan to yellow . Foul Purulent
How to I become a Wound Care Certified RN?
- Wound, Ostomy, Continence – BSN or higher degree required
- Foot Care – BSN or higher degree required
- Advanced Practice Wound, Ostomy, and Continence – requires MSN or higher degree to become an Advanced Practice Registered Nurse (APRN) (Nurse Practitioner, Clinical Nurse Specialist, etc.)
How do you document wound in nursing?
Use the body as a clock when documenting the length, width, and depth of a wound using the linear method. In all instances of the linear (or clock) method, the head is at 12:00 and the feet are at 6:00. When measuring length, the ruler will be placed between the longest portion of the wound between 12:00 and 6:00.
What would you document for a wound assessment?
A wound assessment must be made and accurately recorded at every dressing change: the size of the wound, its depth, colour and shape, as well as the condition of surrounding skin, should all be documented.
How do you write a wound Report?
10 Steps for Writing a Wound Care Case ReportTalk to Colleagues: ... Conduct Research: ... Seek Permission: ... Compile the Patient Background and History: ... Document Wound Assessment: ... Describe Treatment Protocol: ... Document Results: ... Include Photo Documentation and Clinical Data:More items...•
How do you document as a nurse?
Tips for Great Nursing DocumentationBe Accurate. Write down information accurately in real-time. ... Avoid Late Entries. ... Prioritize Legibility. ... Use the Right Tools. ... Follow Policy on Abbreviations. ... Document Physician Consultations. ... Chart the Symptom and the Treatment. ... Avoid Opinions and Hearsay.More items...
How do nurses describe wounds?
Use correct terminology to describe your findings, such as ecchymosed (bruised), erythematous (red), indurated (firm), edematous (swollen). Wound edges must also be carefully defined. Wound edges can be described as diffuse, well defined or rolled.
How are wounds measured and documented?
The wound is typically measured first by its length, then by width, and finally by depth. The length is always from the patient's head to the toe. The width is always from the lateral positions on the patient. The depth is usually measured by inserting a q–tip in the deepest part of the wound with the tip of finger.
How do you describe wound healing?
Healthy granulation tissue is pink in colour and is an indicator of healing. Unhealthy granulation is dark red in colour, often bleeds on contact, and may indicate the presence of wound infection. Such wounds should be cultured and treated in the light of microbiological results.
How do you write a wound care order?
A well-written order will include all of the relevant components of a wound care regimen listed below:Clean.Debride.Address bioburden.Actively manage wound bed.Hydrate or maintain moisture balance or absorb drainage.Protect periwound skin.Secure and maintain a semi-occlusive environment.Support venous return.More items...•
How would you describe the clinical appearance of a wound?
Wound bed clinical appearance: Granulating- is when healthy red tissue is observed and is deposited during the repair process. It presents as pinkish/red coloured moist tissue and comprises of newly formed collagen, elastin and capillary networks. The tissue is well vascularised and bleeds easily.
What are the basic rules of nursing documentation?
Be clear, legible, concise, contemporaneous, progressive and accurate. Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.
What are the 5 legal requirements for nursing documentation?
The documentation needs to be concise, legible, and clear. There must be accurate information about the actions taken, assessments, treatment outcomes, complications, risks, reassessment processes in treatments, and changes in the treatment.
How do you write nursing notes?
Tips for Writing Quality Nurse NotesAlways use a consistent format: Make a point of starting each record with patient identification information. ... Keep notes timely: Write your notes within 24 hours after supervising the patient's care. ... Use standard abbreviations: Write out complete terms whenever possible.More items...•
Introduction
Documentation in Practice
- Section 10 of the Nursing and Midwifery Council’s code (NMC, 2015) clearly outlines nurses’ record-keeping responsibility (Box 1). However, the task of documentation is not necessarily limited to registered nurses – they can delegate to healthcare assistants, assistant practitioners and nursing students to document the care they have given (Royal College of Nursing, 2012) – s…
Documentation in Wound Care
- A wound assessment must be made and accurately recorded at every dressing change: the size of the wound, its depth, colour and shape, as well as the condition of surrounding skin, should all be documented. This vital information indicates the stage and progress of the wound and is vital to ensure that the next clinician caring for the patient selec...
Wound Assessment
- Various assessment tools are available to help with recording a wound’s condition and progress if a local tool is not available. Examples include HEIDI, TIME, TELER (Box 3) and Bates-Jensen. All assist with accurate documentation and nurses should use the one required by local policy or select the one that best suits the needs of the patient. There are many sophisticated methods fo…
Wound Progression
- The first wound assessment provides the benchmark against which progress can be measured. The second may show the wound has grown as debris is removed (Fletcher, 2011). If the wound is going to heal, there will be a distinct difference in its condition by the third and fourth week. The type of tissue in a wound can also provide information on its progress towards healing. Treatme…
Conclusion
- Accurate and continuous measurement of wounds, and consistent and clear documentation, are vital to ensure good outcomes for patients. Wounds are far more likely to heal if their progress is monitored and nurses treat them accordingly. Documentation need not be a laborious task, and in any case is a professional and legal requirement; failure to complete documentation can lead to …