Wound documentation sheet


Wound bed preparation extends the existing practice of using a holistic approach to evaluate and remove all barriers to healing, so that wound repair can progress normally. The overall goal of management is to achieve a stable wound that has healthy granulation tissue and one that is characterized by a well-vascularized wound bed. For example: your patient insists on sitting in their wheelchair and going to the smoking room for long periods of time, or out of the facility all day. You should document a discussion about risk of pressure ulcers. If your patient has a wound, document your discussions with the patient or caregiver about their wound care. 9. Most podiatry-specific EMRs have built-in wound care templates, which makes the wound documentation easier, according to Dr. Suzuki. He notes that more sophisticated wound care specific EMRs can extract and sort the data for the purpose of research or as a benchmark against the other EMR users in the rest of the country. Dr. Wound Assessment Flow Sheet Cheat Sheet drainage on it Draw an X [ on the diagram to indicate the location of the wound Place a check in the box that represents the wound type: Pressure ulcer: a wound due to pressure +/- wound … surface area = length x widthfriction Surgical wound: an intentional disruption in the skin Pathway Health Services Wound Documentation Guidelines When charting a description of a pressure ulcer, the following components should be a part of your weekly charting. 1. LOCATION 2. STAGE Pressure ulcers ONLY per NPUAP Definitions on previous page OR for lower extremity wounds (arterial, venous and neuropathic) use the following definitions: