DOCUMENTATION
Document a full patient history including:
Initiating event and the duration of the wound
Previous treatments and their outcomes
Diabetes control and prior complications
Medical conditions that may interfere with wound healing
Medications that may interfere with wound healing
Underlying pathophysiology
Psycho-social barriers to wound healing
Severity of pain
Other Important Wound Documentation
Routine skin assessment and care
Moisture management
Nutritional status
Change in clinical status or wound healing progress
Education and follow up with the patient, family, and caregivers
Discuss family adherence to plan of care
Repositioning and turning schedules
Pressure-reducing support surfaces (both bed and chair)
Document referral to specialist and/or programs including:
Nutritional management
Diabetes management
Smoking cessation
Vascular surgeon
Interventional Radiologist
Allergist
Infectious Disease
Matthew Livingston R.N. C.W.S.