Chapter 17: Wound Care Documentation

Overview

Wound Care Documentation is where you assess, track, and document all patient wounds throughout their care. The system provides comprehensive tools for wound assessment, measurement, photo documentation, and treatment tracking.

What You'll Learn:

How to access the Wound Care Flowsheet
How to document multiple wounds for a single patient
How to measure wounds accurately
How to upload wound photos
How to document wound treatment
Where wound documentation appears in the system

Who Should Read This Chapter:

Skilled Nurses (RN)
Licensed Practical Nurses (LPN/LVN)
Wound Care Specialists
Clinical Managers
Anyone documenting wound assessments

Prerequisites:

Patient has been admitted (Chapter 14)
Patient has an active care order (Chapter 15)

17.1 Understanding Wound Documentation in the System

Two Ways to Document Wounds

The system provides two distinct methods for wound documentation:

Method 1: Wound Worksheet (Patient-Level)

Purpose: Comprehensive wound assessment flowsheet
Storage: One active worksheet per patient (patient-level, not visit-specific)
Access From:
- Patient Profile page
- Inside SN Visit forms (Integumentary section)
- Inside LPN Visit forms (Assessment section)
- Inside OASIS forms (Integumentary Status tab)
Use Case: Ongoing wound tracking across multiple visits
Capacity: Up to 5 wounds simultaneously

Method 2: Wound Care Note (Visit-Specific)

Purpose: Standalone visit documentation for wound care visits
Storage: Stored with each specific visit
Access From:
- Wound Care Note visit type (dedicated visit form)
Use Case: Documenting a dedicated wound care visit
Capacity: Unlimited wounds (add as many as needed per visit)

Key Difference:

Wound Worksheet = Patient's current wound status (one version, updated over time)
Wound Care Note = Documentation of a specific wound care visit (snapshot at that visit)

17.2 Accessing the Wound Care Flowsheet

From Patient Profile Page

Go to Patients in the left sidebar
Click on a patient's name to open their profile
Scroll down to find the "View Wound Worksheet" button
Click to open the Wound Care Flowsheet modal

From Inside Visit Forms

The "WOUND WORKSHEET" button appears in these forms:

Skilled Nursing (SN) Visit:

Go to the Integumentary section
Click the "WOUND WORKSHEET" button at the top

LPN/LVN Visit:

Go to the Assessment section
Click the "WOUND WORKSHEET" button

OASIS Forms (SOC, ROC, Recertification, Discharge):

Go to the Integumentary Status tab
Click the "View Wound Worksheet" button

17.3 The Wound Care Flowsheet Screen

Wound Care Flowsheet

Modal Title: "Wound Care Flowsheet"

Body Diagram (Top Section)

At the top of the screen, you'll see:

Front view (left side) - body diagram showing front of body
Back view (right side) - body diagram showing back of body

Purpose: Visual reference to help identify and document wound locations on the body.

17.4 The Wound Assessment Table

The main section displays a table with up to 5 wound columns:

Wound One
Wound Two
Wound Three
Wound Four
Wound Five

Each column represents a separate wound on the patient. If a patient has 3 wounds, you'll fill out columns 1, 2, and 3.

Table Rows (What to Document)

The table has 14 rows for documenting each wound's characteristics:

Upload File
Location
Onset Date
Wound Type
Pressure Ulcer Stage
Measurements
Wound Bed (%)
Surrounding Tissue
Drainage
Drainage Amount
Odor
Tunneling
Undermining
Device

Let me explain each row in detail.

17.5 Documenting Each Wound Field

Row 1: Upload File

What It Does: Allows you to upload a photo of the wound

How to Use:

In the wound column, find the Upload File row
Click "Choose File" button
Select a wound photo from your device
The system uploads and attaches it to this specific wound
Once uploaded, you'll see the filename and a "Delete" button

When to Upload:

At wound onset (baseline photo)
Weekly for acute wounds
Bi-weekly for chronic wounds
When significant changes occur
Before discharge

File Format: Images only (JPEG, PNG, etc.)

Row 2: Location

What It Does: Records where on the body the wound is located

How to Use:

Click in the Location text field for the wound column
Type the specific body location

Examples:

"Left Heel"
"Right Hip"
"Sacrum"
"Left Lower Leg - Lateral"
"Right Elbow"

Best Practice: Be specific. Instead of "leg," write "right lower leg, medial aspect."

Row 3: Onset Date

What It Does: Records when the wound first appeared

How to Use:

Click in the Onset Date field
Select the date from the calendar picker
Format: MM/DD/YYYY

Why It Matters:

Tracks wound duration
Helps determine healing progress
Important for billing and compliance

Row 4: Wound Type

What It Does: Describes the type/cause of the wound

How to Use:

Click in the Wound Type text field
Type the wound type

Common Wound Types:

Pressure Ulcer
Surgical Incision
Diabetic Ulcer
Venous Stasis Ulcer
Arterial Ulcer
Traumatic Wound
Burn
Skin Tear
Abrasion

Row 5: Pressure Ulcer Stage

What It Does: Classifies the depth/severity of pressure ulcers

How to Use:

Click the Pressure Ulcer Stage dropdown
Select the appropriate stage

Options:

I - Intact skin with non-blanchable redness
II - Partial thickness loss (blister, shallow open ulcer)
III - Full thickness tissue loss (fat visible, no bone/tendon/muscle exposed)
IV - Full thickness tissue loss with exposed bone, tendon, or muscle
Unstageable - Full thickness loss, base obscured by slough or eschar

When to Use: Only for pressure ulcers. Leave blank for other wound types.

Row 6: Measurements

What It Does: Records the physical dimensions of the wound in centimeters

How to Use: Each wound column has 3 measurement fields:

Length (cm) - Longest dimension (head to toe)
- Enter number (e.g., "3.5")
Width (cm) - Widest dimension (side to side)
- Enter number (e.g., "2.0")
Depth (cm) - How deep the wound is
- Enter number (e.g., "0.8")
- Use a sterile cotton-tipped applicator to measure depth

Measurement Technique:

Always measure in the same position
Use a disposable ruler
Measure length head-to-toe, width side-to-side
Round to nearest 0.1 cm

Why It Matters:

Tracks healing or deterioration
Length × Width = approximate surface area
Depth indicates tissue involvement

Row 7: Wound Bed (%)

What It Does: Describes the tissue composition visible in the wound bed

How to Use: Each wound column has 3 percentage fields:

Granulation % - Healthy pink/red tissue
Slough % - Yellow/tan devitalized tissue
Eschar % - Black/brown dead tissue

IMPORTANT: The three percentages must total 100%

Examples:

Healing wound: 80% Granulation, 15% Slough, 5% Eschar
Infected wound: 30% Granulation, 60% Slough, 10% Eschar
Necrotic wound: 10% Granulation, 20% Slough, 70% Eschar

What Each Means:

Granulation: Good! This is healing tissue with new blood vessels
Slough: Needs debridement - dead tissue that's separating
Eschar: Needs debridement - hard, dry dead tissue (stable heel eschar may be left intact)

Row 8: Surrounding Tissue

What It Does: Describes the condition of the skin around the wound

How to Use:

Click the Surrounding Tissue dropdown
Select the option that best describes the tissue

Options:

Redness - Inflamed, may indicate infection
Pink - Normal healing color
Dry - Lacks moisture
Pale - Possible poor circulation
Moist - Appropriate moisture balance
Excoriated - Damaged from moisture/friction
Calloused - Thickened, hardened skin
Normal - Healthy surrounding tissue

Row 9: Drainage

What It Does: Describes the type of fluid coming from the wound

How to Use:

Click the Drainage dropdown
Select the type

Options:

Serous - Clear, watery fluid (normal)
Serosanguineous - Clear with pink tinge (blood-tinged, often normal)
Purulent - Thick, cloudy, pus (indicates infection)
None - No drainage present

Clinical Significance:

Serous/Serosanguineous = Usually normal healing
Purulent = Infection - notify MD

Row 10: Drainage Amount

What It Does: Quantifies how much drainage is present

How to Use:

Click the Drainage Amount dropdown
Select the amount

Options:

None - No drainage
Minimal - Small amount (dressing slightly damp)
Moderate - Medium amount (dressing 25-75% saturated)
Heavy - Large amount (dressing saturated, may strike through)

Row 11: Odor

What It Does: Records any smell from the wound

How to Use:

Click in the Odor text field
Type the description

Common Descriptions:

"None"
"Foul" (may indicate infection or necrotic tissue)
"Musty"
"Sweet" (may indicate Pseudomonas infection)

Best Practice: Assess odor after cleaning the wound, not before.

Row 12: Tunneling

What It Does: Documents channels that extend from the wound bed under intact skin

How to Use: Each wound column has 2 tunneling fields:

Length (cm) - How deep the tunnel goes
- Use a sterile cotton-tipped applicator to measure
- Enter number (e.g., "2.5")
Time (o'clock) - Direction of the tunnel
- Use clock face method (patient's head = 12 o'clock)
- Select from dropdown: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12

Example: "3.0 cm at 2 o'clock" means a tunnel 3 cm deep extending toward the patient's right side.

Why It Matters:

Tunneling can hide infection
Prevents healing from the inside out
Requires packing to heal properly

Row 13: Undermining

What It Does: Documents tissue destruction under intact wound edges (erosion under the skin)

How to Use: Each wound column has 3 undermining fields:

Length (cm) - How far the undermining extends
- Enter number (e.g., "1.5")
From (o'clock) - Starting position
- Select from dropdown: 1-12
To (o'clock) - Ending position
- Select from dropdown: 1-12

Example: "1.5 cm from 10 to 2 o'clock" means undermining extends 1.5 cm deep from 10 o'clock position around to 2 o'clock position.

Clock Face Reference:

Patient's head = 12 o'clock
Patient's feet = 6 o'clock
Patient's right side = 3 o'clock
Patient's left side = 9 o'clock

Row 14: Device

What It Does: Documents any devices applied to the wound (e.g., negative pressure wound therapy)

How to Use: Each wound column has 2 device fields:

Type - What device is being used
- Enter text (e.g., "VAC Therapy," "Wound VAC," "Negative Pressure")
Setting - Device settings/parameters
- Enter text (e.g., "125 mmHg continuous," "100 mmHg intermittent")

When to Use:

Only if a wound therapy device is in use
Leave blank if no device

Common Devices:

VAC (Vacuum-Assisted Closure)
Negative Pressure Wound Therapy
NPWT
Pulsed Lavage

17.6 Treatment Performed Section

Location: Below the wound assessment table

What It Does: Free-text area to describe the treatment you provided during this visit

How to Use:

Click in the "Treatment Performed" text box
Type a detailed description of the wound care provided

What to Include:

Wound cleaning method (e.g., "Cleansed with normal saline")
Debridement performed (e.g., "Sharp debridement of loose slough")
Products applied (e.g., "Applied silver alginate dressing")
Packing method (e.g., "Loosely packed tunnel with moistened gauze")
Secondary dressing (e.g., "Covered with ABD pad and secured with tape")
Skin protection (e.g., "Applied barrier cream to periwound skin")

Example Entry:

Cleansed wound with normal saline. Performed sharp debridement of loose yellow slough from wound bed. Loosely packed wound with saline-moistened gauze. Applied foam dressing and secured with transparent film. Applied barrier cream to surrounding skin to protect from moisture. Patient tolerated procedure well.

17.7 Narrative Section

Location: Below the Treatment Performed section

What It Does: Free-text area for clinical narrative and patient response

How to Use:

Click in the "Narrative" text box
Type your clinical notes and patient response

What to Include:

Patient's response to treatment
Pain level during/after care
Patient/caregiver education provided
Patient/caregiver understanding demonstrated
Signs of infection (or absence thereof)
Healing progress observations
Plan for next visit

Example Entry:

Patient reports pain level 3/10 during dressing change, improved from 5/10 last visit. Wound showing signs of improvement with increased granulation tissue and decreased slough. No signs of infection noted - surrounding tissue pink, drainage serous, no foul odor. Educated patient on importance of offloading pressure and keeping heel elevated. Patient verbalized understanding and demonstrated correct positioning. Continue current treatment plan. Will reassess in 3 days.

17.8 Saving the Wound Worksheet

How to Save:

After documenting all wounds, click the blue "Save" button at the bottom right
Success message appears: "Wound worksheet saved successfully" or "Wound worksheet updated successfully"
Click "Cancel" to close the modal without saving (you'll lose unsaved changes)

Important Notes:

The system maintains one active wound worksheet per patient
When you save, it updates the patient's current wound worksheet
All forms and the patient profile access this same worksheet
If you close the modal without saving, changes are lost

17.9 Viewing Wound Photos

After Upload:

The filename appears in the Upload File row
Click the filename to view the full image
Click "Delete" to remove the photo if needed

Photo Tips:

Take photos from the same angle each time
Include a ruler in the photo for scale
Ensure good lighting
Take photos after cleaning the wound
Document photo date in your system

17.10 Common Wound Care Scenarios

Scenario 1: New Pressure Ulcer on Admission

Steps:

Open the patient's Wound Worksheet
Use Wound One column
Fill in:
- Location: "Sacrum"
- Onset Date: Date discovered
- Wound Type: "Pressure Ulcer"
- Pressure Ulcer Stage: "II" (if partial thickness)
- Measurements: Length, Width, Depth
- Wound Bed: Percentages (e.g., 70% Granulation, 30% Slough, 0% Eschar)
- Surrounding Tissue: "Redness"
- Drainage: "Serous"
- Drainage Amount: "Minimal"
- Odor: "None"
- Upload baseline photo
Document treatment in Treatment Performed
Document assessment in Narrative
Click "Save"

Scenario 2: Patient Has 3 Active Wounds

Steps:

Use columns Wound One, Wound Two, Wound Three
Fill out complete assessment for each wound separately
Example:
- Wound One: Sacral pressure ulcer
- Wound Two: Left heel pressure ulcer
- Wound Three: Right lower leg venous ulcer
Upload photos for each wound
Document treatment for all wounds in Treatment Performed
Click "Save"

Scenario 3: Wound Healed - Removing from Worksheet

What Happens:

When a wound heals, you typically leave it documented with final measurements showing 0 × 0 × 0 cm
Update the Wound Bed to show 100% Granulation
Document "Wound healed, epithelialized" in Treatment Performed
Take final photo
For your next visit, you can clear that column and reuse it for a new wound if needed

Best Practice: Document the healed wound in your visit note narrative for that visit before clearing the column.

17.11 Wound Worksheet vs. Visit Forms

When You Update the Wound Worksheet

The Changes Apply To:

Patient's current wound status
Any future visit forms that open the worksheet
The patient profile

The Changes DO NOT Apply To:

Past completed visits (those have their own snapshots)
Past OASIS assessments (those are locked once approved)

Example Timeline:

Monday: You document 3 wounds in the Wound Worksheet during an SN Visit
Wednesday: You update measurements showing improvement
Friday: QA approves Monday's visit
Next Monday: You open the Wound Worksheet again
- You'll see Wednesday's updated measurements (current status)
- If you view Monday's approved visit, it shows Monday's measurements (snapshot)

Key Point: The Wound Worksheet shows the current state. Past visits show historical snapshots.

17.12 Best Practices

Measurement Accuracy

✅ Use the same measuring technique each time
✅ Measure with patient in same position
✅ Use a disposable ruler
✅ Round to nearest 0.1 cm
❌ Don't estimate - always measure

Documentation Frequency

Acute wounds: Weekly measurements minimum
Chronic wounds: Bi-weekly measurements minimum
Rapidly changing wounds: Every visit
Stable wounds: Weekly minimum

Photo Documentation

✅ Take at admission (baseline)
✅ Weekly for first month
✅ Bi-weekly thereafter if stable
✅ Whenever significant changes occur
✅ Before discharge (final photo)
❌ Don't take photos before cleaning the wound

Wound Bed Percentages

✅ Always total 100%
✅ Reassess each visit
✅ Use to track healing progress
Example: Week 1: 40% granulation → Week 2: 60% granulation = Improving!

Clinical Indicators to Report to MD

⚠️ Purulent drainage (infection)
⚠️ Foul odor (infection or necrosis)
⚠️ Increased redness around wound (cellulitis)
⚠️ Wound size increasing
⚠️ Exposed bone, tendon, or muscle (Stage IV)
⚠️ Patient fever with wound present
⚠️ Severe pain at wound site

17.13 Troubleshooting

Problem: "Wound bed percentages must total 100%"

Solution: Check your granulation, slough, and eschar percentages. They must add up to exactly 100.

Example: 70% + 20% + 10% = 100% ✅
Example: 60% + 30% + 5% = 95% ❌

Problem: Can't upload wound photo

Possible Causes:

File is too large (try smaller file size)
File format not supported (use JPEG or PNG)
No internet connection

Solution:

Compress the image
Convert to JPEG or PNG format
Check your connection and try again

Problem: Don't see my updated wound measurements in last week's visit

Explanation: This is normal! Past completed visits show a snapshot of the wounds at that time. Current measurements appear in:

Today's visit forms
The patient's Wound Worksheet (current status)
Future visits

17.14 Key Takeaways

✅ The Wound Worksheet tracks up to 5 wounds simultaneously for one patient
✅ The worksheet is patient-level (one active version per patient)
✅ Access from patient profile, SN visits, LPN visits, and OASIS forms
✅ 14 assessment fields per wound (location, measurements, photos, etc.)
✅ Wound bed percentages must total 100%
✅ Use clock face method for tunneling and undermining (head = 12 o'clock)
✅ Upload photos for visual tracking
✅ Document treatment performed and patient response
✅ Changes to the worksheet update the current status only
✅ Past completed visits retain their historical snapshots