Introduction

Wound documentation is critical for the delivery of effective wound care, the facilitation of care continuity, and proper health data coding.¹ Inaccurate wound documentation can impact the ability to determine the best wound treatment options and the overall wound healing process.² Unfortunately, almost half of all medical record notes on wounds lack key details on assessment and intervention in some settings.^{3, 4}

What Should Be Considered for Wound Documentation?

Proper wound care documentation can be broken up into several categories. 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.
• Partial-thickness wounds – tissue destruction through the epidermis that extends into but not through the dermis
• Full-thickness wounds – tissue destruction that extends through the dermis to involve subcutaneous tissue and possible bone or muscle
• Wound size measured in centimeters to include length, width, and depth
• Wound bed characteristics, including tissue amounts and types (granulation, slough, eschar, epithelialization)
• Indication of infection, including fever, erythema, increased drainage, odor, warmth, edema, elevated white blood cell count, induration, and pain

How to Document the Perimeter of the Wound

• Description of wound edges
• Definition – defined or undefined wound edges
• Attachment – attached or unattached wound edges
• Epibole – rolled wound edges
• Maceration – white skin that is sometimes wrinkled and soft as a result of supersaturation
• Callused or fibrotic edge – a buildup of tissue at the wound margin caused by hyperkeratosis
• Description of periwound area, including the color, presence or lack of edema, tissue consistency (indurated, boggy, etc.), temperature, and other noted traits

How to Document Wound Exudate

Wound exudate can manifest in many forms. Considering the type and amount of exudate is often a determining factor for dressing types and other intervention methods.

• Wound exudate type⁵
• Serous – thin, watery, clear
• Sanguineous – thin, bright red, with fresh bleeding
• Serosanguineous – thin, watery, pale red to pink
• Purulent – thick or thin, opaque tan to yellow
• Foul purulent – thick opaque tan to green, with odor
• Wound exudate amount⁵
• None – wound tissue dry
• Scant – wound tissue moist. with no measurable drainage
• Minimal – wound tissue moist. with less than 25% of the dressing saturated over 24 hours
• Moderate – wound tissue wet. with 25% to 75% of the dressing saturated over 24 hours
• Large – wound tissue filled with fluid, with greater than 75% of the dressing saturated within 24 hours

Specific Conditions

Once the wound’s etiology has been identified, clinicians must further document the wound using the etiology’s measurements of intensity. Recording this information allows wound care professionals to track the wound’s progress.

How to Document Pressure Injuries

Pressure injuries are often at the forefront of wound care professionals’ minds because of their prevalence and resilience to treatment once they have developed, among other reasons. For pressure injuries, the stage and type of injury (medical device–related pressure injury, mucosal membrane pressure injury) should be documented, as follows:

• Stage 1 – intact skin with a localized area of nonblanchable erythema
• Stage 2 – partial-thickness loss of skin with exposed dermis and a viable wound bed
• Stage 3 – full-thickness loss of skin with visible adipose tissue
• Stage 4 – full-thickness loss of skin and tissue with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone
• Unstageable –wound obscured by slough or eschar, so the extent of full-thickness skin and tissue loss cannot be confirmed
• Deep tissue injury – intact or nonintact skin with a localized area of nonblanchable discoloration or epidermal separation revealing a dark wound bed

How to Document Intervention Methods

Once the wound etiology has been determined, wound care professionals can properly assess which interventions to use to facilitate healing.

• Method of debridement, if applied
• Autolytic
• Enzymatic
• Mechanical
• Sharp or surgical
• Biologic
• Undermining, tunneling, or sinus tracts, with the location and extent as well as any interventions (such as the number of foam pieces used in a wound and how many are removed)
• Undermining – the destruction of tissue that extends under the skin edges (margins) and causes the pressure injury to be larger at its base than at the skin surface
• Tunneling –a narrow passageway that may extend in any direction within the wound bed
• Sinus tract – an elongated cavity that allows purulent material from an abscess to drain to the body surface

Important to Document: Patient-based Variables

• Reports of pain, including location, causative factors, intensity, duration, etc.
• Patient refusal of care or nonadherence to treatment plans
• Interventions to promote healing, such as dietary supplements, vitamins, laboratory tests, repositioning, offloading, incontinence management, and skin care
• Conditions that negatively affect healing, such as impaired mobility and nutritional status
• Anticipated wound outcome

General Documentation Practices

It can be difficult to know what to document, and many variables depend on the unique wound and patient characteristics. Here are additional examples of items that should be included in the documentation and where documentation can be found⁵:

• Initial intake
• Daily notes
• Weekly progress notes
• Weekly skin reports
• Current treatment plan
• Responses to treatments
• Changes in the treatment plan
• Resident or caregiver education provided
• MD notification
• Implementation of new orders
• Reasons for not changing a treatment plan
• Referrals
• Refusal of care

Conclusion

Medical documentation and records serve multiple purposes. First and foremost, they should plan and provide for continuity of care for a patient’s medical treatment. However, they can also document compliance with external laws and regulations.⁶ For these reasons, clinicians must provide adequate and accurate documentation of all relevant wound characteristics, interventions, and responses.

References

1. Barakat-Johnson M, Jones A, Burger M, et al. Reshaping wound care: evaluation of an artificial intelligence app to improve wound assessment and management amid the COVID-19 pandemic. Int Wound J. Published online February 25, 2022. doi:10.1111/iwj.13755
2. Coleman S, Nelson EA, Vowden P, et al. Development of a generic wound care assessment minimum data set. J Tissue Viability. 2017;26(4):226-240.
3. Hansen RL, Fossum M. Nursing documentation of pressure ulcers in nursing homes: comparison of record content and patient examinations. Nurs Open. 2016;3(3):159-167.
4. Gillespie BM, Chaboyer W, Kang E, et al. Postsurgery wound assessment and management practices: a chart audit. J Clin Nurs. 2014;23(21-22):3250-3261.
5. American Medical Technologies. Reference for wound documentation. 2018. Accessed April 16, 2022. amt-wound-documentation-reference_-_updated_per_6.21.18_meeting.pdf
6. Hess CT. Focusing on wound care documentation and audits. Adv Skin Wound Care. 2019;32(9):431-432.