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Ulcer Documentation

After assessing a wound, proper documentation is necessary for medical, legal and reimbursement reasons. A photograph of the wound is the most reliable documentation. Your charting should include the following information on each wound care visit:

  • Patient's name and date of visit
  • Vital signs - temp., pulse, respiration, blood pressure
  • Are the dressings intact? - (wet, dry, loose, clean, dirty)
  • Strikethrough - Is there drainage on the outside of the dressing material?
  • Location of wound - foot, leg, thigh, sacrum, elbow, shoulder, right, left, dorsal, plantar, medial, lateral, anterior, posterior, etc.
  • Size - length, width and depth measured in centimeters. (use a sterile cotton tip applicator to measure depth). DO NOT CROSS CONTAMINATE WOUNDS by using the same gloves, instruments, measuring devices, etc. if the patient has multiple wounds. Based on previous measurements, is the wound improving, deteriorating or remaining stagnant.
  • Tracking - defined as skin overhanging a dead space
  • Undermining - look for skin that overhangs the wound's edges
  • Drainage - Is there drainage on the contact layers of the dressing? What does it look like (serous, purulent, bloody, green, yellow, clear, thick, etc.) Is the drainage a breakdown of the wound dressing (like a hydrocolloid) or actual drainage from the wound? Yellow purulent drainage could indicate staphylococcus involvement. Green drainage could indicate pseudomonas involvement. Estimate the amount of drainage present.
  • Odor - Is there any odor from the wound? This can offer a great deal of information on which organism may be contaminating or infecting a wound. Fruity smell points toward staphylococcus organisms. Foul odor (fecal like) points toward gram negative bacteria.
  • Necrotic tissue - What percentage of the wound appears to be necrotic tissue. Necrotic tissue should be considered as any tissue that is not beefy red and granular. Where is the necrotic tissue? Draw a small diagram.
  • Infection - Is the wound red (or streaking redness), hot and swollen? Is there soreness out of proportion to what should be present given the patient's medical history and the progression and etiology of the wound? Infection should be assessed both clinically and with the help of lab data such as vitals and WBC count.
  • Stage pressure ulcers - refer to the section on staging pressure ulcers for a complete review. In short, an ulcer with an intact eschar should be noted as unstageable due to eschar formation. I strongly recommend that you DO NOT reverse stage a healing ulcer. For example, an ulcer initially documented as a stage 4 should not be documented as a stage 2 or a stage 1 as it heals. The reason is simple. Skin over a healed ulcer is only 70 - 80 percent as strong as undamaged skin. A new health care professional on the case may look at the latest notes and only see a stage 2 in the assessment and not realize that this patient is at high risk. I like to document that the wound is a healing stage 4 ulcer.
  • Classify non pressure ulcers - use Wagner classification for foot ulcers. Use "full thickness" or "partial thickness" phrasing to document other types of ulcers. Wagner Classification is as follows:
    • Grade 0 - Pre-ulcerative lesion, healed ulcers, presence of bony deformity
    • Grade 1 - Superficial ulcer without subcutaneous tissue involvement
    • Grade 2 - Penetration through the subcutaneous tissue (may expose bone, tendon, ligament, or joint capsule)
    • Grade 3 - Osteitis, abscess, or osteomyelitis
    • Grade 4 - Gangrene of the forefoot
    • Grade 5 - Gangrene of the entire foot
  • Past treatment - Note the past treatments and any changes in products. This will help new health care professionals on the case. Products that may not have produced the desired results won't be accidentally duplicated.
  • Current treatment - Document the type of irrigation, products and secondary dressings used during the dressing change.
  • Signature - Sign the bottom of the note.
  • Follow up - Contact the appropriate doctor, nurse, therapist or other health care professional to discuss your findings, especially if there is deterioration.

This page authored By Dr. Allan Freedline and Dr. Tamara D. Fishman. 

Copyright 1995 - 2013