Assessment and Documentation of Wounds


One of the goals of Healthy People 2010 is “to increase quality and years of healthy life”. The home-health nurse can be instrumental in assisting to meet this objective. With an increasing aging population whose preference is to remain in their home, increasing institutional health care costs and changes in the nuclear family, a large proportion of home care cliental are single elderly individuals with no or limited support system. A population with age-related changes that result in many types of wounds such as decubitus ulcers, skin cancers, injuries, and diabetic or circulatory related ulcers.

I found it interesting to read that United States spends about 10 to 15 billion annually (Canadian $ are comparable) in treating chronic wounds, with many of these being treated in a homecare setting. With this in mind, it is Important for health care professionals to provide these two crucial elements 1) initial and ongoing wound assessment and 2) accurate documentation. Quality documentation is important for medical, legal and reimbursement reasons, as well as serves as a communication tool to all team members.

Health care professionals should have access to methods of documentation that are quick, easy, specific and precise, and should include a) Wound Assessment, b) Photo documentation c) Pain Assessment and d) a Care Plan.

Wound Assessment: There are a number of useful wound assessment tools available. Two that I found very comprehensive were the Wound Assessment Parameter Scoring Tool (WAPST) and the other was the Wound Assessment Chart Guidelines (WACG). Both offered clear and concise parameters for ongoing documentation of the wound; however the WACG offers a chart for wounds in various anatomical locations and specific assessments for specific areas. For example, the Leg Ulcer Assessment Chart included documentation for tibial and pedal pulses. These assessment charts were very good for describing the wound appearance; however the health care team must be knowledgeable in use of the terminology such: necrotic, slough, granulation, overgranulation, and epithelialisation. The definitions of these terms are provided with the WACG system.

Photo Documentation: Proponents of photo documentation suggest that photos are the most reliable and accurate means of documentation. Photos are taken upon admission or during the initial assessment; with these serving as a reference for future images. They provide a clear, visual image of either the healing or deterioration of the skin integrity. All photos should include a wound measurement guide strip or a measurement grid. Photos may be sent electronically to the attending physician. When well done, a picture can greatly reduce the amount of written description necessary for accurate documentation and avoid confusing anecdotal records.
Conversely, some feel that photo documentation has limited uses in our homecare system due to the sometimes poor quality of the images as a result of lighting, positioning of camera etc, generally due to user inexperience, and that they are an added expense. However, newer technologies such as the Polaroid Light Lock Close-up Lens ™ have reduced these user errors. Photo documentation does require that all nurses be trained in use of the camera, along with ongoing in-services to ensure that staff remains updated.

Pain Assessment: Wound pain is a relatively new consideration in wound care. Research related to wound pain indicated that individuals with pressure ulcers experienced moderate pain about 80% of the time. It was determined that pain is related to patient well-being and is always subjective. “Pain is whatever the experiencing person says it is, existing whenever the person says it does” (McCaffery, 1968). Two common pain assessment tools are the Pain Intensity Scale and the Paces Pain Rating Scale. All clients should be assessed for pain at each visit and measures taken to eliminate or to control the pain.

Care Plan: Wound Assessment, Photo Documentation and Pain Assessment are all key components in evaluating the wound status, on which changes in the care plan are based. Past treatments, and changes in product usage should be noted in the event of staff changes so products or treatments that did not produce the desired effect are not repeated.

Wound and pain assessment and documentation should be factual, comprehensive and timely. An accurate depiction of the wound is an important legal protection. Ambiguity can be risky as documentation is legal evidence of the quality of wound care that has been provided. As the saying goes, “If you didn’t document it, you didn’t do it.”

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