documenting wounds in the care plan

[Ann Avery]

Greetings I am looking for clarification re- documenting wounds in the care plan - would the Wound stage be documented in the Care plan - or just the nursing diagnosis and plan to treat?

Thank You, Ann Avery

[seaofclouds21, BSN, RN]

That will depend specifically on your facilities charting. We have specific wound assessment forms we fill out for wound/skin assessments. Then our care plan has comments about wound healing, but not really the description/staging of the wounds.

[amoLucia]

As above in LTC for me.

[nortonplusRN]

In my facility, we put the stage of the wound in the careplan and we update as necessary.