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Wound Care Documentation

Wound   (3,072 Views 4 Comments)
by Ariel09 Ariel09 (Member) Member

1,143 Profile Views; 19 Posts

Hi, I am a new treatment nurse of about 5 months and I am struggling with how to document properly. I know documentation in wound care is extremely important and I would love some advice from experience wound care nurses! Any good books, websites etc. Thank you!!

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Eagle2110 has 5 years experience as a ADN, BSN, CNM and specializes in Wound Care.

108 Posts; 5,378 Profile Views

Hi and welcome to the world of wound care!!

Woundconsultant.com has some useful information. I once was a treatment nurse in a nursing home and pretty much had to educate myself. I now work for a wound care center and they provide an abundance of training. If your facility does not have their own established policy and procedures regarding documentation, or no one in-house who's very knowledgeable, maybe they would allow you to spend a day at a wound care clinic in order to learn enhance your documenting and wound care skills. Just a thought.

Hope this helps!

Edited by Eagle2110
Weird symbols. Reread your question.

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19 Posts; 1,143 Profile Views

Hi! Thank you! My ultimate goal is to someday work at a wound care center, right now I am trying to gain all the experience I can and even though this is tough I absolutely LOVE it! Thank you for responding, truly appreciate it.

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18 Posts; 707 Profile Views

Hi Ariel, I have worked in long term wound care for about 8 years. I too struggled with documentation. I did a lot of research and self education. Here is a outline of what I use: condition of current dressing, wound shape, depth, edges, undermining, necrotic tissue type, necrotic tissue amount, exudate type, exudate amount, odor, skin surrounding wound, indications of infection, pain, peripheral tissue edema or induration, granulation tissue, epithelialization, wound status, interventions for healing, conditions affecting healing, current treatment, patient and caregiver education. this will about cover all wounds, you will just need to plug in some descriptors and vascular assessment if a vascular ulcer. I hope this helps. I have pages and pages of descriptors. too many to post here. again I hope this helps.

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