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
- Are the dressings intact? - (wet, dry, loose,
- 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
- Tracking - defined as skin overhanging a dead
- Undermining - look for skin that overhangs the
- 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
- 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
- Grade 2 - Penetration through the subcutaneous
tissue (may expose bone, tendon, ligament, or
- 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
- 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.