Wound Care Documentation

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Wound Care Documentation - May 30, 2003 5:32:00 PM

PTCHRIS

Posts: 1
Joined: May 29, 2003
From: Michigan
Status: offline

I am a therapist currently working in acute care/hospital setting. Our team is working to develop/establish a wound evalation/documentation form. I was curious if anyone had examples from their own facility as well as key information to include on such a form. Appreciate your feedback THanx

Post #: 1

Re: Wound Care Documentation - June 1, 2003 12:51:00 PM

tucker

Posts: 182
Joined: May 24, 2003
From: Texas
Status: offline

Areas to cover in the wound eval would be:

Periwound:
Skin color around wound, peripheral tissue edema, peripheral tissue firmness

Drainage of the wound:
Exudate type, exudate amount

Architecture of the wound:
Length, Width, Depth, Edges, Undermining, tunnelling (direction, depth)

Surface of the wound:
Necrotic type, necrotic amount (%), granulation tissue color, granulation amount (%), epithelialization (%)

Visuals:
Photograph taken, tracing made.

Good body diagrams so you can indicate exactly where the wound is.

Our wound eval is mostly a check-off list with specified answers for each category. For example, exudate type would have sanguinous, serous, serosanguinous, purulent (color).. I actually prefer writing this out but the categories make sure you document it.

FYI- Carrie Sussman's "Wound Care" is probably the best book out there for PT wound care. There is a chapter on wound evals and samples. I think there is a second edition now. Good luck!

(in reply to PTCHRIS)

Post #: 2