Tips for Effective Wound Documentation

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Tips for Effective Wound Documentation
www.woundemr.com
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Accurate wound documentation is a vital part of
monitoring, treating, and managing wounds. Proper
wound management with improved technologies can
promote wound healing and thus prevent further
complications.
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Wound documentation should be consistent and
concise. Nowadays, most healthcare facilities use
wound management software to document details
such as
CMS recommends a weekly thorough assessment with
daily monitoring of the dressing and wound to
assess for complications in long-term care
patients.
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Documented Wound Assessment Details Should
Include

• History Of Present Illness
• Wound Area
• Size
• Condition Of Wound Edges
• Surrounding Skin
• Pain
• Odor
• Discharge Plan, And More

• Infection Signs
• Risk Assessment
• Procedures Performed
• Supplies And Tests Ordered
• Any Conditions Which Would
• Affect Healing
• Response To Treatment
• Care Plan

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Tips for Standardized Wound Documentation
Wound photographs serve as a permanent record.
Images of wounds along with the corresponding
notes on size, shape, fluid and tissue type
allows better understanding of your
documentation.
It is important to note down the medications
provided and the type of dressing used to dress
the wound.
Make sure to document relevant details in charts.
Documentation charts for each hospital will be
different. 
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WoundWizard - Comprehensive  Wound Care EHR
A comprehensive wound care EHR can improve
clinical and operational efficiencies and
maximize workflow. WoundWizard provides you with
a total wound care solutions management program.
It is ideal for Long Term Care Facilities,
Hospitals, Wound Care Centers and other
healthcare facilities.
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If you would like to schedule a demo or want
further information about WoundWizard web-based
EMR, contact us.
WoundWizard941 McLean Avenue, Suite
387 Yonkers, NY 10704
Tel 855-WOUNDWIZARD      855-968-6394Fax
208-279-8681
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