Help with documentation
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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!