Documentation of Wounds and Care
When documenting:
- Include type of wound (and cause, if applicable), location, size, color, drainage and any undermining.
- Use a wound care flow sheet for capturing details. CGS has an example that HHAs may use as a guide when creating their own sheets.
- Use objective terms, e.g., "2 cm of bloody drainage on pad", rather than "moderate".
- If unsure of etiology of wound, ask the patient's physician.
- Be consistent in documenting etiology of wound – pressure ulcer, stasis, diabetic ulcer.
- Remember wounds are documented in the OASIS, visit notes and POC. Consistent documentation of the type of wound from clinician to clinician is essential.
- If possible, have the same clinician measure the wound each time for consistency.
CGS Resources:
Updated: 12.19.16