Pressure ulcers, leg ulcers, surgical wounds, and skin tears are common in care home populations. Good documentation enables consistent care across shifts, supports clinical decision-making, and provides crucial evidence for regulatory compliance.
Initial Wound Assessment
When a wound is first identified, conduct and document a comprehensive assessment:
Wound Details
- •Type of wound (pressure, surgical, trauma)
- •Location (use body map)
- •How and when it occurred
- •Duration if existing wound
- •Previous treatments tried
Wound Bed
- •Tissue type (granulating, sloughy, necrotic)
- •Percentage of each tissue type
- •Colour description
- •Presence of foreign bodies
- •Epithelialisation at edges
Surrounding Skin
- •Colour (normal, erythema, maceration)
- •Temperature compared to other skin
- •Condition (dry, moist, fragile)
- •Oedema present
- •Signs of infection spreading
Exudate
- •Amount (none, light, moderate, heavy)
- •Type (serous, sanguineous, purulent)
- •Colour
- •Odour (none, mild, offensive)
- •Impact on dressing wear time
Wound Measurement
Accurate, consistent measurement is essential for tracking healing. Document:
Linear Measurement
Measure length (head to toe) and width (side to side) at the widest points. Record in centimetres.
Depth
Use a sterile probe to measure deepest point. Document undermining and tunnelling with direction (clock face).
Photography
Take photos with a ruler in frame for scale. Consistent positioning, lighting, and camera angle each time.
Photography Consent
Ensure you have documented consent for wound photography. Store images securely as part of the clinical record, following your organisation's image policy.
Pressure Ulcer Classification
For pressure ulcers, document the category/stage:
Category 1
Non-blanchable erythema of intact skin. Skin intact but red, warm, or painful. Does not blanch when pressed.
Category 2
Partial thickness skin loss. May appear as blister or shallow open wound with red/pink wound bed.
Category 3
Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
Category 4
Full thickness tissue loss. Bone, tendon, or muscle exposed. May include undermining and tunnelling.
Unstageable
Full thickness loss with wound bed obscured by slough or eschar. True depth cannot be determined.
Deep Tissue Injury
Purple or maroon localised area of intact skin or blood-filled blister. Damage to underlying soft tissue.
Important
Pressure ulcers do not "downgrade"—a healed Category 3 remains documented as Category 3, now healed. Never change the original category as it heals.
Treatment Documentation
Record every dressing change and treatment:
- Date and time: When treatment was provided
- Wound assessment: Current appearance, any changes
- Cleansing: Solution used and method
- Dressing applied: Type, size, and rationale
- Secondary dressing: If applicable
- Pain: Before, during, and after treatment
- Next review: When dressing should be changed
- Signature: Who performed the treatment
Signs of Infection
Document and escalate these warning signs:
Local Signs
- Increased pain or tenderness
- Increased warmth around wound
- Spreading redness (cellulitis)
- Increased or purulent exudate
- Offensive odour
- Wound breakdown or enlargement
- Delayed healing
Systemic Signs
- Fever (>38°C)
- Elevated white cell count
- General malaise
- Confusion (especially in elderly)
- Elevated inflammatory markers
- Sepsis signs
Care Plan Documentation
The wound care plan should document:
Wound management goal
Healing, maintenance, palliation? Realistic timeframe expectations.
Treatment regimen
Prescribed dressing type, frequency, any medications.
Prevention measures
Repositioning schedule, pressure relief equipment, nutrition support.
Pain management
Analgesia requirements, timing relative to dressing changes.
Review schedule
When to reassess, who should review (TVN, GP).
Escalation criteria
When to contact GP, TVN, or hospital.
Body Maps
Use body maps to clearly identify wound locations:
- Mark exact location on standardised body outline
- Number multiple wounds for consistent reference
- Include date wound first identified
- Update map when new wounds develop
- Reference map number in treatment records
Specialist Referrals
Document all specialist involvement:
- Tissue Viability Nurse (TVN) assessments and recommendations
- GP reviews and prescribing decisions
- Dietitian input for nutritional support
- Vascular assessments for leg ulcers (ABPI)
- Follow-up actions and outcomes
CQC Expectations
Inspectors assess wound care documentation specifically. They expect:
- Comprehensive initial assessment
- Regular reassessment with clear measurements
- Evidence-based treatment choices
- Photographic evidence where appropriate
- Clear escalation when wounds deteriorate
- Preventive measures documented for at-risk residents
- Staff competency in wound assessment
Healing Progress
Track and document healing indicators:
- Reduction in wound dimensions over time
- Improvement in wound bed appearance
- Decrease in exudate levels
- Resolution of infection signs
- Epithelialisation at wound edges
- Reduction in pain levels
Documentation Quality Checklist
Conclusion
Wound documentation should tell the complete story of each wound—from how it developed, through treatment, to healing or ongoing management. Good documentation enables consistent care across multiple staff members and provides the evidence needed to demonstrate quality care.
Remember: if it isn't documented, it didn't happen. In wound care, thorough documentation protects residents, staff, and your organisation.
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