Week 6 | Wound Management Documentation (16180-SP)

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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

  • Flowsheets
  • Narrative
  • Electronic Medical Records


Documentation Practice

Objectives for Learning Outcomes

After completing this session, you will be able to:

  1. Describe the essential elements to include in wound management documentation. 
  2. Identify tools utilized for assessment of healing.
Course summary

Renee Anderson, MSN, RN, CWON
Certified Wound Ostomy Nurse; Co-Director, Wound Management Education Program (WMEP) and Wound Management Fundamentals Course (WMFC), Continuing Nursing Education, University of Washington School of Nursing, Seattle; President, Rainier Clinical Consultants, Inc, Seattle, WA

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