Documenting half healed scabs

Published

I'm not a wound nurse, I'm a private duty nurse and noticed my patient had a very large scab over his shin bone. He said he scrapped it the other day. It's for the most part completely covering the open skin, but there are a few open areas where it must have been picked off or scraped off by other actions.

I have absolutely no idea how to document it. All I said in my notes was that a large scab was noted on the left lower extremity over the tibia and that no s/s of infection were present.

Up Vote Up Vote ×
Specializes in CWON - Certified Wound and Ostomy Nurse.

You have a good start with what you've already mentioned and believe it or not you have written more than what I typically see for wound documentation. Measurements are important. Probably should elaborate a bit more on the no s/s of infection. Any odor? Exudate? Amount of exudate? Appearance? Erythema? If so, how far does it extend from the wound? Any edema or induration? What type of dressing did you apply?

Up Vote Up Vote ×

Awesome, thank you.

Up Vote Up Vote ×
+ Join the Discussion