16 Documentation of Dressing Change
As the community nurse, you are required to document the dressing change.
Sample Documentation
Left chest dressing removed for scant, dry, serosanguineous drainage. Steri strips intact, with a small amount of old, dry sanguineous drainage. Bruising noted proximal to incision line. There is no redness around the incision site. JP dressing changed for scant amount of dry sanguineous drainage, cleansed around the exit site with normal saline, and new mepore dressing applied. Gauze dressing applied over left chest steri strips. Janet is comfortable managing her dressing and drain at this time. Questions answered and will visit again in 2 days.