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Assessment and Documentation of Chronic Wounds Evaluation and documentation of chronic wounds are important. This will help in providing appropriate and timely treatment that promotes wound healing.

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A wound that fails to heal in an orderly set of stages and within a predictable amount of time (usually 3 months) the way most wounds do, are chronic wounds.

There are many types of

chronic wounds. These include venous stasis ulcers, arterial ulcers, diabetic ulcers, pressure ulcers, traumatic ulcers and post-surgical wounds. Chronic wounds including leg or pressure ulcers may require debridement to promote wound healing. Nurses or clinical staff team members may need to document a debridement while working with the patient’s physician. The physician will review these notes to determine the best treatment plan for the patient. Wound care software for nurses that is being

increasingly

used

in

hospitals

helps

in

better

documentation.

Assessment of Chronic Wounds Both the patient and the wound should be evaluated accurately to develop an appropriate plan of care. When the patient is admitted to a hospital, healthcare providers should conduct a general head-to-toe physical examination, focusing on the patient’s height, weight, and skin characteristics. Measuring the www.woundemr.com

855-968-6394


patient’s height and weight would ensure appropriate nutritional and pharmacologic management. In addition to that, healing processes such as hemostasis, inflammation, proliferation and remodeling should be evaluated periodically to manage chronic wounds effectively. In fact, a complete assessment of the wound must include the following. ❖ Identifying the cause of the wound ❖ Patient’s medical history including medication history ❖ Associated attributes, host factors and environmental factors ❖ Anatomic location of the wound ❖ Size of the wound ❖ Shape of the wound whether curved, linear, irregular or straight ❖ Presence of foreign material in or around the wound ❖ Circumference and depth of the wound ❖ Any undermining/tunneling/sinus tracts ❖ Any drainage (exudate) including amount, color, and odor ❖ Various types or characteristics of tissue in wound bed

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855-968-6394


❖ Wound edges ❖ Surrounding tissue such as color, edema, firmness, intact, induration, pallor, lesions, texture, scar, rash, staining and moisture ❖ Signs of infection ❖ Pain level ❖ Interventions for healing such as dietary supplements, vitamins, lab tests, turning repositioning schedules, support surface, cushion, padding, pillows, elevation, heel

protection,

incontinence

management,

skin

protection (barrier ointments) ❖ Conditions that could impede wound healing such as patient’s nutritional status, mobility/turning surface and positioning limitations, continence, abnormal labs, infections, deterioration of medical condition, and noncompliance. ❖ Current topical treatment plan, response to treatment, modifications to plan, implementation of new orders, reason for not changing treatment plan and referrals. ❖ Patient and caregiver education

www.woundemr.com

855-968-6394


Healthcare providers should clearly document the assessment details and treatment provided to help other healthcare providers make appropriate decisions regarding a patient’s care plan. Woundcare EHR helps healthcare providers to successfully and efficiently complete the task of documenting.

www.woundemr.com

855-968-6394

Assessment and documentation of chronic wounds  

Evaluation and documentation of chronic wounds are important. This will help in providing appropriate and timely treatment that promotes wou...

Assessment and documentation of chronic wounds  

Evaluation and documentation of chronic wounds are important. This will help in providing appropriate and timely treatment that promotes wou...

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