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tucker -> Re: Wound Care Documentation (June 1, 2003 12:51:00 PM)
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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!
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