Editor's note: This blog was originally published on January 25, 2018. It was updated and republished on December 17, 2020.

Scope of Practice and Standards of Practice guide nurses¹ and other members of the interprofessional wound care team² in caring for patients with wounds. Documentation in the medical record is a key aspect of the standard of practice and serves to record the care delivered to the patient or resident. Your documentation should follow your facility guideline for documentation. Accurate documentation helps to improve patient safety, outcomes, and quality of care.^3,4 This WoundSource Trending Topic blog considers general wound documentation dos and don'ts and presents 10 tips for success. Good, better, and best documentation examples are included for each tip.

Wound Documentation Tip #1: Visual Inspection

Do describe what you see: type of wound, location, size, stage or depth, color, tissue type, exudate, erythema, condition of periwound.

Don't guess at the type or the stage of a pressure ulcer or injury (hereafter, pressure injury [PI]) or the depth of the wound. Write "etiology (or depth) cannot be determined" or "unstageable" and/or consult a wound care expert.

Examples: Good – Purple area over sacrum. Etiology cannot be determined.

Better – 2-cm diameter purple area over sacrum. Skin intact. Could be a bruise or a deep tissue injury (DTI). Etiology cannot be determined.

Best – 2-cm diameter purple area over sacrum. 2-cm surrounding erythema. Skin intact. No depth noted on palpation. Could be a bruise; possible DTI. Implemented PI protocol. Wound Care consulted. Assess sacral area at every shift. Low–air loss (LAL) mattress ordered.

Wound Documentation Tip #2: Pressure Injury Risk Assessment

Do perform a PI risk assessment (e.g., Braden Scale for Predicting Pressure Sore Risk©), and document the score regularly per your facility guideline. Stay in the moment. Think of the score as a snapshot of the person at one single point in time.

Don't rely on previous risk assessment scores. Your risk assessment score is unique and should reflect the specific moment that you are performing the assessment.

Examples: Good – Braden Score 15. Implemented PI prevention protocol.

Better – Braden Score dropped from 19 to 15. Resident occasionally incontinent. PI prevention protocol and incontinence protocol implemented.

Best – Braden Score dropped from 19 to 15. Changes in incontinence and nutrition subscores noted. Implemented PI prevention protocol and incontinence protocol. Nutrition consult ordered.

Wound Documentation Tip #3: Precise Use of Language

Do be very specific in your note about any of your communications with other health care providers, the patient or resident, or the family (e.g., "Informed Dr. Jones at 10:30 AM about change in Mr. Smith's wound status [describe]").

Don't generalize and just document statements such as "Physician aware." You may be called upon at a much later date to explain what happened (e.g., in a deposition), and all you will probably have to refresh your memory is your note. So be sure it is as detailed and relevant as possible. The devil's in the detail.

Examples: Good – Wound draining. Dr. Smith’s office called at 10:30 AM with status update.

Better – Heel ulcer draining yellow pus. No c/o pain. No fever. Amy at Dr. Smith’s office notified at 10:30 AM; request for new dressing orders, awaiting call back.

Best – Diabetic foot/pressure injury right heel, previously red and granulating. Now draining yellow pus. Area around ulcer warm. No systemic S/S of infection. Amy at Dr. Smith’s office notified at 10:30 AM; awaiting call back from Dr. Smith to discuss and get his recommendations for changes in the plan of care.

Wound Documentation Tip #4: Pertinent Information to Include

Do record pertinent information in your wound care note, such as any changes in the wound parameters, pain level, overall patient or resident condition, or interventions. Aim for consistency among providers in their wound care notes.

Don't just document "Dressing changed" or "Dressing dry and intact" or "Turned q2h" in your note. It is better to document such observations in a checklist instead of a note.⁵ Avoid redundant charting.

Examples: Good – Santyl* dressing to ankle changed. Wound status quo. No pain with dressing change.

Better – Santyl dressing to right lateral malleolus wound changed. Stage 4 PI. 70% granulation tissue, 30% slough. No pain with dressing change.

Best – Santyl dressing changed to right lateral malleolus stage 4 PI, 1 cm × 2 cm × 0.5 cm. Decreasing amount of slough noted – now 70% granulation tissue, 30% slough. Santyl effective and not causing pain. Continue current plan of care.

Wound Documentation Tip #5: Wound Category Changes

Do document when a wound changes category (i.e., a skin tear evolves into a PI, or a PI becomes a surgical wound after a surgical repair, or a DTI evolves to a stage 4 PI).

Don't document a skin tear, moisture-associated skin damage, a venous ulcer, an arterial ulcer, or a wound with any other etiology as a PI.

Examples: Good – Skin tear to left buttock. Now deeper: 4 × 0.5 × 0.5 cm. Changed dressing from film to foam.

Better – Skin tear to left buttock, now evolving into a PI. 4 × 0.5 × 0.5 cm. Dressing changed from film to foam. Implemented PI protocol.

Best – Skin tear to left buttock evolving into a stage 3 PI, 4 × 0.5 × 0.5 cm. Moderate amount of serous exudate. Dressing changed from film to foam for exudate management and reduced shear to area. Implemented PI protocol. LAL mattress ordered.

Wound Documentation Tip #6: Patient Behaviors

Do describe in the medical record behaviors of patients or residents who are non-adherent to (non-compliant with) the plan of care. Document conversations, plans to address the behaviors, educational interventions, etc.

Don't be judgmental about a patient's or resident’s non-adherence (non-compliance), and don't just continue "business as usual." The patient or resident may have to be discharged from your care if the non-adherence continues.

Examples: Good – Resident refused to be turned and repositioned at 2:00 PM. Will come back later and try again.

Better – Resident refused repositioning at 2:00 PM. Explained importance to turning and repositioning, but resident still refused. She says it hurts to lie on her sides; wants to lie on back only.

Best – Resident refusing to turn off her back, onto her sides, for PI prevention. She c/o pain when lying on her sides. Buttocks reddened. Braden Score 12. Called Nurse Practitioner to discuss matter. LAL mattress to be ordered and q12h pain medication and will be re-evaluated in 72 hours.

Wound Documentation Tip #7: Refusal of Treatment

Do describe in the medical record the who, what, where, why, and when of a patient or resident who refuses a treatment or care. Document how you educated the patient or resident and other options that were offered.

Don't be judgmental about a patient's or resident’s refusal of a treatment or care. It is a patient’s or resident’s right to refuse.

Examples: Good – Patient refused to allow nurse to change dressing to dehisced surgical wound yesterday and again today. Surgeon’s office notified.

Better – Patient crying and distressed over dressing change to dehisced midline surgical wound. Refused dressing change yesterday and again today. She says she’s too upset to allow anyone but the surgeon to touch the wound. Surgeon’s office called, details discussed with staff, and awaiting call back.

Best – Patient crying and distressed over dressing change to dehisced midline surgical wound. Refused dressing change yesterday and again today. She says she’s too upset to allow anyone but the surgeon to touch the wound. Physician Assistant Thomas and Dr. Jones’ (surgeon) office notified. STAT dose of anti-anxiety medication given per PA Thomas. Explained to patient that Dr. Jones will come later to observe the wound, change the dressing, and write new orders for wound care. Patient expressed understanding and says she is relieved.

Wound Documentation Tip #8: HIPAA-Appropriate Photography

Do follow your facility guideline regarding photography and how to store and HIPAA protect the photos.

Don't cut corners when it comes to photographs, and follow your facility guideline precisely to avoid HIPAA violations.

Examples: Good – Admission skin and wound photos taken × 16 per policy.

Better – Admission skin and wound assessments completed. Resident has 16 skin/wound areas. One photo taken of each and uploaded to the EMR per policy.

Best – Admission skin assessment completed. Rashes present to both axillae, under both breasts, and in both groin folds. Two skin tears. 1 surgical incision. 7 PIs documented on PI tool. 16 admission photos taken and uploaded to the EMR per policy.

Wound Documentation Tip #9: End-of-Life Wounds

Do distinguish end-of-life wounds (also known as Kennedy terminal ulcers, SCALE [skin changes at life's end] wounds, skin failure, terminal ulcers) from PIs or other wounds.

Don't document end-of-life wounds as "PIs" in patients or residents who are on the dying trajectory. Consider these wounds as having their own category.

Examples: Good – Open area to sacrum noted yesterday. Today area is worse. End-of-life wound?

Better – Resident placed on hospice 1 week ago. Developed open area to sacrum yesterday. Area much deeper today. Silicone adhesive foam border dressing applied.

Best – Resident placed on hospice 1 week ago. Yesterday area to sacrum opened up to a partial-thickness wound. Full-thickness wound observed today. Possible end-of-life wound. Dr. Martin notified. Palliative wound care orders obtained and initiated with silicone adhesive foam border dressing.

Wound Documentation Tip #10: Unavoidable Pressure Injuries

Do document, if applicable, in the medical record the circumstances that make a PI "unavoidable" for an individual patient or resident: risk factors, comorbidities, conditions.

Don't avoid addressing the issue of "unavoidability" in the medical record if it is relevant to an individual patient's wound.

Examples: Good – Sacral area purple on admission 2 days ago. Now covered with black eschar.

Better – Patient admitted 2 days ago s/p fractured hip with a fall at home. 4-cm purple area to sacrum present on admission. Area now 4 × 4 × 2 cm and covered with black eschar.

Best – Patient admitted two days ago s/p fractured hip with a fall at home. Family reports that she was on the floor for over 12 hours before someone found her. 4-cm purple area to sacrum present on admission (suspected DTI). Area now full-thickness open wound, black eschar at base, 4 × 4 × 2 cm. *Product name used as an example and not as an endorsement.

References

1. American Nurses Association (ANA). Nursing: Scope and Standards of Practice Nursing. 2nd ed. Silver Spring, MD: ANA; 2010.

2. Krasner DL, van Rijswijk, eds. Chronic Wound Care: The Essentials e-Book. Malvern, PA: HMP Communications; 2018. Downloadable for free at www.whywoundcare.com

3. McCarthy B, Fitzgerald S, O'Shea M, et al. Electronic nursing documentation interventions to promote or improve patient safety and quality care: a systematic review. J Nurs Manag. 2019; 27(3):491-501.

4. Tuinman A, de Greef MHG, Krijnen WP, Paans W, Roodbol PF. Accuracy of documentation in the nursing care plan in long-term institutional care. Geriatr Nurs. 2017;38(6): 578-583.

5. Gawande A. The Checklist Manifesto: How to Get Things Right. New York: Picador; 2011.

Other Resources

Capriotti T. Document Smart: The A-to-Z Guide to Better Nursing Documentation. 4th ed. Philadelphia, PA: Wolters Kluwer; 2020. Gelety KS. Nursing Notes the Easy Way: 100+ Common Nursing Documentation and Communication Templates. 2nd ed. Fort Peirce, FL: Nursethings; 2011.

Kettenbach G, Schlomer SL. Writing Patient/Client Notes: Ensuring Accuracy in Documentation. 5th ed. Philadelphia, PA: FA Davis; 2015. Mosby's Surefire Documentation. 2nd ed. St. Louis, MO: Mosby Elsevier, 2006.

Myers E. RNotes: Nurse’s Clinical Pocket Guide. 5th ed. Philadelphia, PA: FA Davis, 2018.

Stout K, ed. Nursing Documentation Made Incredibly Easy. 5th ed. Philadelphia, PA: Wolters Kluwer; 2019. Sullivan DD. Guide to Clinical Documentation. 3rd ed. Philadelphia, PA: FA Davis; 2019.

About the Author

Diane Krasner, PhD, RN, FAAN is a Wound and Skin Care Consultant in York, PA. She is a former Clinical Editor of WoundSource and has served on the WoundSource Editorial Advisory Board since 2001. Check out Dr. Krasner's website for complementary resources on Skin Changes At Life's End (SCALE), wound pain, and the Why Wound Care? Campaign at www.dianelkrasner.com.