Documenting half healed scabs

Specialties Wound

Published

I'm not a wound nurse, I'm a private duty nurse and noticed my patient had a very large scab over his shin bone. He said he scrapped it the other day. It's for the most part completely covering the open skin, but there are a few open areas where it must have been picked off or scraped off by other actions.

I have absolutely no idea how to document it. All I said in my notes was that a large scab was noted on the left lower extremity over the tibia and that no s/s of infection were present.

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Specializes in CWON - Certified Wound and Ostomy Nurse.

You have a good start with what you've already mentioned and believe it or not you have written more than what I typically see for wound documentation. Measurements are important. Probably should elaborate a bit more on the no s/s of infection. Any odor? Exudate? Amount of exudate? Appearance? Erythema? If so, how far does it extend from the wound? Any edema or induration? What type of dressing did you apply?

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Awesome, thank you.

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