Wound Documentation

Wound documentation is a critical aspect of nursing practice that involves accurately assessing and documenting the characteristics of wounds. This guide provides tips for wound assessment and documentation, including wound measurements, types of wounds, signs of abnormal wound healing, and assessment of the wound bed, wound edge, and periwound skin.

Table of contents

Wound documentation: step-by-step

There are 3 overall areas of wound assessment and documentation:

1. Wound bed
2. Wound edge
3. Peri-wound skin

How to assess the wound bed

Assess and document the following:

1. Location: Where is the wound?
2. Type: What kind of wound is it?
3. Wound tissue: Granulation, slough, or necrotic tissue?
4. Wound measurements: Include length, width, and depth.
5. Exudate: Note amount of exudate, color, consistency, and odor.

How to assess the wound edge

• Maceration (softening of tissues by soaking in fluids)
• Tunneling (erosion of tissue under wound edges causing pocket beneath skin)
• Rolled edge (wound edges rolling over themselves causing body to think wound has healed → healing ceases prematurely)

How to assess periwound skin

• Redness, warmth, edema, pain, skin breakdown
• Areas of maceration, excoriation, dry skin, hyperkeratosis, callous, eczema

Related videos

What supplies are needed for assessing wounds?

• Measuring tape
• Sterile cotton tip applicator

What are the different types of wounds?

The different types of wounds include:

• Incision
• Laceration
• Abrasion
• Puncture wound
• Pressure wound

How to classify and document wound exudate

• Amount: scant, moderate, large, copious
• Color: serous, sanguineous, serosanguineous, purulent
• Consistency: thin, thick, tenacious
• Odor: no odor, foul

What are the signs of abnormal wound healing?

Signs of abnormal wound healing include:

• Increased pain or swelling
• Stiff movement in affected limb
• Pus or odorous exudate
• Tunneling
• Erythema of peri-wound skin
• Wound gaping open or not healing
• Red streaking from or around the wound

When do wounds need to be documented?

• When a client is first admitted and wounds are found during head-to-toe assessment
• When there is a change in an existing wound
• On a regular schedule depending on the situation
• Following procedures related to the wound like dressing changes (documenting procedure as well as client’s response)
• Upon discharge or transfer

Wound documentation example

Date: June 28, 2023

Location: right lower leg, lateral

Size: length 4 cm, width 3 cm, depth 2 mm

Wound bed appearance: wound bed 70% covered in red granulation tissue, 30% yellow slough; no necrotic tissue present

Exudate: moderate amount of serosanguinous drainage noted, no odor detected

Pain: client reports pain level as 4 on a 0–10 scale, describes a ‘burning’ sensation

Peri-wound skin: skin pink, warm to touch, no signs of infection; mild edema present

Wound edges: well-defined, not rolled

Treatment: wound cleansed with normal saline; topical hydrogel applied then absorbent dressing applied and secured with paper tape

Client Response: tolerated procedure well, reports decreased pain following dressing application

Progress: compared to last assessment on June 26, 2023, wound length decreased by 1 cm, width remains the same, depth decreased by 1 cm; granulation tissue increased by 20%