Wound Documentation

Wound documentation is a valuable process that helps clinicians to monitor the progress of a wound. Newer technology and point of care innovations have paved the way for documentation using wound photography, digital measurements, and electronic health records. Electronic wound documentation platforms also allow for real-time reporting. (See Figure 1). Wound assessment parameters should be documented in a consistent format to facilitate comparison and communication to team members. This begins with a comprehensive patient and wound history, along with a detailed wound assessment.

Table 1 – Sample of a Wound Electronic Documentation (Humber River Hospital, 2021). Used with Permission.

Drainage Amount None              Small (Scant)             Moderate                Large
Wound Drainage
 Drainage Description Serous
Purulent (yellow, green or brown)
Other – if selected, specify
Other (Specified)
Periwound / Edge Assessment
Periwound/Edge Intact            Excoriated                   Rolled
Bleeding      Induration                   Undermining/Tunneling
Dry                 Macerated
Signs of Infection
Signs of Superficial Infection Non-healing                                               Debris
Exudate Increased                                 Smell
Red & Bleeding (Friable)
*** 3 or More, Use Topical Antimicrobial***
Signs of deep and Surrounding Tissue Size is Larger                                              Exudate Increased
Temperature Increased                       Erydate  and Edema
Exposed or Probe to Bone                 Smell
New Breakdown
Wound Measurement
Length (cm)
Width (cm)
Area (cm)
Depth (cm)

When assessing a wound, the specific location should be identified and documented e.g. left heel, coccyx, right gluteal fold or lower leg.  Often, multiple wounds may also be present in one location at a time. Wound cleansing should be preformed prior to wound assessment for improved visualization of the wound bed in its natural state. When wound debridement occurs, wound measurements should be recorded both pre and post debridement.

The MEASURE mnemonic is a well accepted framework for detailed wound assessment (Keast et al, 2004). Other validated assessment tools include the Bates-Jensen Wound Assessment Tool or Pressure Ulcer Scale for Healing.

Figure 2 – Additional factors to consider for wound assessment


Additional factors to consider for wound assessment

Share This Book