Week 5 | Wound Management Documentation (17170-SP)

Photo of a patient chart.

Content Outline

  • Purpose 
  • Key Elements 
    • Reason for consultation 
    • Brief medical history 
    • Wound history 
    • Factors impacting healing 
      • ​Tissue perfusion/oxygenation 
      • Nutritional status 
      • Infection 
      • Diabetes 
      • Corticosteroids 
      • Age 
      • Stress 
      • Immunosuppression 
    • 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  
  • Photography  
  • Documentation Practice 

Objectives for Learning Outcomes

At the end of this course work the learner will be able to:

  1. Describe the essential elements to include in wound management documentation. 

  2. Identify tools utilized for assessment of healing.

Additional Information

Course summary

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


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