INTRODUCTION

Overview

This topic provides sample policies on Wound Assessment, Documentation and Photography. It serves as a starting point for organizations to tailor according to their specific needs and care settings, and shall not be considered as a detailed description of all elements that may be required by an organization. It is recommended that all organizational stakeholders, including Quality and Legal departments provide input in the development and updates of wound care policies and procedures.  

WOUND ASSESSMENT AND DOCUMENTATION

Goal

• The aim of the policy is to establish a minimum standard of wound care assessment and documentation for patients with wound management needs.

Policy Elements

• Initial and Regular Assessments: all wounds will be assessed upon admission or occurrence, at least weekly, upon significant changes, and upon transfer or discharge.
• Documentation: documentation should be undertaken in accordance with the wound care and assessment form/template in the electronic medical records as applicable. The wound should be photographed at this time and weekly thereafter, or more often as indicated/ordered. 
• Assessment: wound assessment should be conducted as described in 'Procedures' below
• Patient Care and Education: patients and caregivers should be educated on wound care procedures and receive instructions on signs of infection or complications and when to seek medical attention.
• Interdisciplinary Collaboration: coordination with the healthcare team should be in place, including nurses, physicians, and specialists, to ensure comprehensive wound management. Regular communication and updates on wound status and treatment plans is recommended
• Wound Care Clinicians: All professionals performing wound care should have appropriate credentials, training and certifications and should provide services within their scope of practice. Professionals may include but are not limited to: 
• Registered Nurses (RNs)
• Nurse Practitioners (NPs)
• Physicians (MDs, DOs)
• Physician Assistants (PAs)
• Licensed Practical Nurses (LPNs) or Medical Assistants (MAs) 
• Therapists (physical, occupational)
• Dietitians
• Quality Assurance and Compliance:
• Regular audits and reviews of wound care documentation and practices should be conducted periodically.
  
• The wound care program will adhere to established guidelines and protocols to ensure high-quality care.
• Confidentiality: Patient confidentiality will be maintained. All wound care documentation and photographs will be safely handled by professionals providing care.

Procedures 

At minimum, the following parameters should be documented. See topics "How to Assess a Patient with Chronic Wounds" and "Chronic Wounds Essentials - Quick Reference"

• A. Comprehensive history, physical examination will be performed at each visit.
• B. Wound Cleansing:
• Use sterile saline or appropriate wound cleanser to clean the wound.
• Avoid using antiseptics that may delay healing unless specifically indicated.
• B. Perform wound examination including the following elements:
• C. Anatomic Location: The specific location of skin breakdown.
• D. Wound Measurements (manual method): wounds will be measured in centimeters using the clock method, to ensure consistency:
• Clock method: With a head-to-toe orientation, measure the longest length head-to-toe, and the widest width side-to-side, perpendicular (90-degree angle) to length. That is, the head is always 12 o'clock and feet are always 6 o'clock. Measurements are obtained from 12 o'clock to 6 o'clock at the longest length, and from 9 o'clock to 3 o'clock at the widest width. 
• Length: to be measured from the 12 o'clock to the 6 o'clock position, with 12 o'clock towards the patient's head and 6 o'clock towards the feet.
• Width: to be measured from side to side, or from the 3 o'clock to the 9 o'clock position.
• Depth: depth of a wound is measured using a sterile, flexible, cotton-tipped applicator to measure the deepest point, perpendicular to the skin surface.
• Put on gloves and gently insert a cotton-tipped applicator into the deepest portion of the wound bed.
• Measure the deepest aspect of the wound to the horizontal plane of the intact wound edge by grasping the applicator with the thumb and forefinger at the point level to the skin surface. 
• Withdraw the applicator while maintaining the position of the thumb and forefinger. 
• Hold the cotton-tipped applicator against the ruler to determine the measurement of depth.
•  All wounds need to have their depth recorded.
• For wounds without depth (e.g. pressure ulcer/injury Stage 1 or deep tissue injury), record depth as “0 cm.”
• For superficial wounds (e.g. minor abrasions, skin tears), estimate the depth of very superficial wounds at 0.1 cm (one millimeter) to reflect the lack of skin integrity. 
• Tunneling (Sinus Tracts): Measure the depth using a sterile cotton-tipped applicator and document using the clock method.
• Don gloves and carefully insert the sterile cotton-tipped applicator into the deepest part of the tunnel.
•  Grasp the applicator at the point where it aligns with the edge of the wound. 
• Hold this pinched section of the applicator against a centimeter ruler to measure the depth of the tunneling. 
• Record the length and specific location of the tunnel using the clock method.
• Undermining: Document the direction and extent of tissue destruction under intact skin, measured with a sterile cotton-tipped applicator.
• First, don gloves and carefully insert a sterile cotton-tipped applicator into the areas where undermining is present. Visualize the wound as if it were the face of a clock, as previously described. The 12 o'clock position corresponds to the wound edge nearest the patient's head. Progress in a clockwise direction, gently probing to determine the extent of undermining (e.g. from the 2 o'clock to the 6 o'clock position).
• Next, insert the cotton-tipped applicator into the deepest part of the undermining. Hold the applicator between your thumb and forefinger at the level of the skin surface. Carefully withdraw the applicator while maintaining the position of your thumb and forefinger. Measure the length from the tip of the applicator to your fingers using a ruler marked in centimeters.
• Document the extent and deepest point of the undermining, for example: "Undermining from 2 o'clock to 6 o'clock position. Deepest point is 2.5 cm at the 3 o'clock position."
• E. Wound Bed Appearance: document type and percentage of tissue in the wound bed.
• F. Wound Edge Appearance: document characteristics such as punched out, rolled, or attached.
• G. Exudate/Drainage: Assess amount and color.
• H. Periwound Assessment:
• All Wounds: Document skin condition around the wound (maceration, induration, erythema).
• Lower Extremity Wounds: Document edema and assess dorsalis pedis and posterior tibial pulses and sensation. For guidance on assessment of pulses, see section 'Palpation' in topic "Arterial Ulcers - Introduction and Assessment".
• I. Signs of Infection: Look for new or increased slough, changes in drainage, poor granulation, sudden high glucose levels, redness, warmth, induration, unusual odor, pain or tenderness, and lack of improvement despite optimal management for 2 weeks.
• J. Pain Assessment: Utilize a visual analog scale or a faces rating scale.
• K. Wound etiology based on assessment. See topic "How to Assess a Patient with Chronic Wounds" 
• L. Classification:
• Pressure Ulcers/Injuries (PU/PI) will be classified according to the National Pressure Injury Advisory Panel (NPIAP) staging system. See topic "Pressure Ulcers/Injuries - Classification/Staging"
• All other wounds will be classified as either "partial thickness" or "full thickness." See topic "Chronic Wounds Essentials - Quick Reference"
• Partial Thickness: Wounds extend through the epidermis and into, but not through, the dermis.
• Full Thickness: Wounds extend through both the epidermis and dermis, and may involve subcutaneous tissue, muscle, and possibly bone.
• Approximated Incisions: Presence of staples, sutures, or adhesive skin tapes.
• M. Patient/Family Education: Educate on signs and symptoms of infection and provide updates on wound status or assessments.
• N. Pressure Ulcer/Injury Reporting (as required per setting; follow your organization's recommendations):
• Present on Admission: PU/PI that are present on admission will be reported to the provider for evaluation and documentation.
• Facility Acquired: PU/PI will be reported to the provider and a quality tracking report will be sent to quality management for potential root-cause analysis.

WOUND PHOTOGRAPHY