Help with documentation

[DN08]

Im working on my documentation, and im having a brain block! What is the proper way to document wound care... It is for a peg tube dressing with no bleeding or drainage. The stapled incision along side the PEG had minimal bloody drainage dried onto the telfa pad, no currect drainage at time of care. And minimal redness around PEG, none at staples. Telfa pad replaced to staples and 4x4s used around peg.. all taped.

CLEANED with normal saline

Thanks in advace!

[Daytonite, BSN, RN]

the stapled incision (if there is an incision i measure it and chart it's length "2 inch vertical incision at left of peg with edges approximated, intact and no open areas noted" and mention " with xx number of staples with no redness noted" or "xx number of staples with some redness noted around each staple") along side the peg had minimal bloody drainage dried onto the telfa pad , no current drainage at time of care (not necessary to mention that drainage isn't occurring at the time of care). and minimal redness around peg (measure and chart the drainage around the peg, i.e. "2mm diameter of redness around exit site of peg tube"), none at staples (this would go up with the description of the incision). telfa pad replaced to staples and 4x4s used around peg.. all taped (telfa is a brand name. "sterile, nonadhesive dressing applied". i might describe the type of tape, otherwise is isn't necessary to chart the dressing was taped.).

i might chart something like this in the sequence of events as they occurred: peg tube dressing changed. small amount of dried bloody drainage on old dressing. ____ inch incision with wound edges well-approximated and 8 staples intact with no redness, swelling or drainage noted from incision. no open areas noted. ____ mm diameter area of redness noted around peg tube but no drainage. sterile, nonadhesive dressing applied. paper tape used."