Wound Documentation: How to Measure and Describe a Wound
Wound documentation should let another clinician picture the wound and judge whether it is improving. Consistency matters as much as detail.
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Location and type
Use anatomical terms and, where relevant, the wound's aetiology, such as pressure, surgical, venous or arterial.
Measurement
A common method is length head to toe, width side to side at a right angle to length, and depth at the deepest point with a sterile applicator, all in centimetres. Undermining and tunnelling are described by clock position, with 12 o'clock toward the patient's head, and length in centimetres. Use the same method every time.
Wound bed, exudate and periwound
- Tissue: granulation, slough, eschar and epithelial tissue, estimated as percentages
- Exudate amount and type: serous, serosanguineous, sanguineous or purulent
- Odour after cleansing, if your protocol asks for it
- Periwound skin: intact, macerated, erythematous, indurated
Treatment and response
Record cleansing, products applied as ordered, patient tolerance and when the next change is due. Photographs should only be taken according to facility policy and consent.