For wounds, we were taught to include the following:
- # of staples/suture (and if they are intact or not)
- stage (ulcers)
I had to do a test-out on a dressing change and we also had to document it. I passed with a perfect, but I'm sure my documentation isn't perfect since I'm still in my first year of my program. Here is what I put:
11/13/08 1410 serous drainage present on dressing. wound is linear, midline and inferior to the umbilicus. wound is 7cm x 2cm (note: we did these on models and it was physically impossible to measure the depth of this incision, but clinically you should include it if possible.) skin is well-approximated c no edema or odor. slight redness around wound edges. cleaned c normal sterile saline and dressed c sterile gauze. name, credentials
Again, it probably isn't perfect, but there is one example and I really hope that it gives you some idea.