Caring for wounds

At a glance…

The author provides strategies and resources to help wound care professionals with documentation and assessment.

Properly addressing the care of wounds among your residents requires skilled care from knowledgeable wound care professionals. The following seven strategies will help you develop proper techniques when assessing and documenting wounds.

Strategy #1

Carefully follow your facility guidelines for wound assessment and documentation. Be sure these guidelines reflect CMS F-tag 314 requirements and are consistent with the Clinical Practice Guideline for Pressure Ulcers from the American Medical Directors Association (AMDA).

To order the AMDA Clinical Practice Guideline for Pressure Ulcers go to

Strategy #2

When assessing a wound, at a minimum describe and document:

  • The exact location (use correct anatomical terminology)

  • The size in centimeters (length x width x depth)

  • The color of the wound bed

  • The condition of the peri-wound skin

Identify and document any wound characteristics that might be clinical red flags, such as: redness, swelling, pain, warmth, odor, exudate (e.g., serous, serosangenous, sangenous, purulent), foreign bodies (e.g., sutures, mesh, prosthetic device), exposed bone.

Strategy #3

If you are uncertain of the wound etiology (e.g., pressure ulcer or venous ulcer or diabetic foot ulcer or incontinence-associated dermatitis or other),

DON’T GUESS. Document that the etiology cannot be determined at this time and seek out a qualified healthcare professional to help you make the determination.

Strategy #4

If it is in your scope of practice and if you have been trained, you can stage pressure ulcers using the National Pressure Ulcer Advisory Panel’s (NPUAP) 2007 staging definitions. All other wounds can be described as partial or full thickness.

You will also want to review the new pressure ulcer clinical practice guidelines from NPUAP and the European Pressure Ulcer Advisory Panel.

Available for purchase from the NPUAP online store: Quick Reference Guide and Clinical Practice Guideline,

Strategy #5

Based on most state practice acts, LPNs monitor and RNs assess. This is an important distinction when it comes to wound care. LPNs should be sure to have an RN co-sign their wound assessments, especially on admission and discharge.

Strategy #6

Any significant change in a wound should be carefully documented on the appropriate form in the treatment record and in the nurse’s notes. Significant changes must be communicated to the attending physician/primary care physician and the power of attorney. Be sure to document who you have notified, when, and what the response was to your notification.

Strategy #7

Wound litigation is at an all-time high. Careful wound assessment and documentation are your best defense. In a court of law, the old adage “If it wasn’t documented, it wasn’t done,” is still commonly invoked. So, be sure to document carefully and thoroughly.

For more information on the legal aspects of pressure ulcer care, download the legal white paper from the Medline Web site at

Diane L. Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN, is a wound and skin care consultant in York, Pennsylvania. She is the Wound, Ostomy, Continence/Special Projects Nurse at Rest Haven-York, a 158-bed facility in York, Pennsylvania. Dr. Krasner is the lead co-editor of

Chronic Wound Care: A Clinical Source Book for Healthcare Professionals (4

th edition) (, the clinical editor of

Wound Source ( and serves as an expert witness in legal cases involving wound care. Long-Term Living 2010 August;59(8):38

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