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Documentation of Wounds and Care

When documenting:

  • Include type of wound (and cause, if applicable), location, size, color, drainage and any undermining.
  • Use a wound care flow sheet for capturing details. CGS has an example that HHAs may use as a guide when creating their own sheets.
  • Use objective terms, e.g., "2 cm of bloody drainage on pad", rather than "moderate".
  • If unsure of etiology of wound, ask the patient's physician.
  • Be consistent in documenting etiology of wound – pressure ulcer, stasis, diabetic ulcer.
  • Remember wounds are documented in the OASIS, visit notes and POC. Consistent documentation of the type of wound from clinician to clinician is essential.
  • If possible, have the same clinician measure the wound each time for consistency.

CGS Resources:

Updated: 12.19.16

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