Week 5 | Wound Management Documentation (15171-SP)
- Key Elements
- Reason for consultation
- Brief medical history
- Wound history
- Factors impacting healing
- Tissue perfusion/oxygenation
- Nutritional status
- Focused wound assessment
- Short and Long Term Goals
- Treatment recommendations
- Plan for follow-up
- Assessment of Healing
- % true area reduction
- Bates-Jensen Wound Assessment Tool (BWAT).
- Pressure Ulcer Scale for Healing (PUSH)
- Documentation formats A. Flowsheets B. Narrative C. Electronic Medical Records
- Documentation Practice
Objectives for Learning Outcomes
At the end of this course work the learner will be able to:
Describe the essential elements to include in wound management documentation.
Identify tools utilized for assessment of healing.
Renee Anderson, MSN, RN, CWON
Certified Wound and Ostomy Care Nurse; Co‐Director, Wound Management Education Program, University of Washington School of Nursing , Seattle; Clinical Faculty, Biobehavioral Nursing & Health Systems University of Washington School of Nursing; President, Rainier Clinical Consultants, Inc., Seattle, WA