Part 1: The Principles of Proper Wound Assessment and Photo Documentation

Tamara D. Fishman, BS, DPM.
Dr Fishman is the President of the Wound Care Institute, Inc.

Reprinted with permission from: Developments, Vol.1 #2 Winter 1996

In 1995, there were approximately 50 million wounds in the United States serious enough for the patient to seek medical evaluation. Wound management, from beginning to end, is an everexpanding and very relevant concern for all health care providers. It is also a very important concern for our government and insurance companies.Treating just the chronic wounds has been estimated to cost between $5 and $7 billion annually, and these wounds are increasing at a rate of 10% per year.

After an accurate assessment of a wound, proper documentation is necessary for medical, legal and reimbursement reasons. The documentation collected can also be used to compile a medical database to further advances in research.The assessment of the wound is the record of the etiology (cause), i.e. diabetic, vascular, pressure, surgical, burn, fistulas or skin tears.

The need for quality documentation is important to provide all wound care team members with a better means to communicate with each other.

Documentation is also important because it serves as the foundation for an effective and consistent plan of care, ensuring quality treatment for the patient or resident.Your documentation should be factual, comprehensive and timely in order to decrease liability and increase your reimbursement.

A photograph of a wound is the most reliable and accurate means of documentation, and serves as a key component in the wound assessment process.

A photo should be taken upon admission and serve as a reference to which an other serial photographs win be compared.These photographs win also serve to provide a clear, visual image of either the healing or deterioration of a patient's/resident's skin integrity. The following factors are key in the photo documentation process:

  1. You must always obtain the patient's/resident's consent prior to taking any photographs.
  2. Be aware of adequate lighting.

    All photographs should include a wound measuremnet guide strip or measurement grid.

    All photographs should include a wound measurement guide strip or measurement grid.

  3. Attempt to take photographs from the same point of reference each time (same distance and angle).
  4. All photographs should include a wound measurement guide strip or measurement grid, plus the patient's/resident's name, date and location of the wound on the body.
  5. Remember to wear protective gloves whenever your hands may become exposed.
  6. Make the photograph a permanent part of the patient's/resident's medical record.

The Polaroids HealthCam®2 System allows you to document your patient's/resident's wounds while showing healing progress at the same time. As a result, the use of photo documentation is a very valuable resource in terms of supporting reimbursement claims.The system is also exceHent for educating and communicating with patients/residents and their caregivers.

Keys to Ensure Accurate Wound Documentation

Proper documentation during each wound care visit is necessary to establish an accurate, serial record of healing.To ensure proper documentation, the following information should be recorded in the patient's/resident's chart for each wound care visit:

  • Patient's/resident's name and the date of the wound care visit.
  • Vital signs, including temperature, pulse, respiration and blood pressure.
  • Are dressings intact? wet? dry? loose? clean? dirty?
  • Strikethrough - is there drainage on the outside of the dressing material?
  • Accurate location of the wound (foot, leg, thigh, sacrum, elbow, shoulder, right, left, dorsal, planter, medial, lateral, anterior, posterior, etc.).
  • Tracking occurs when the wound extends far beyond the wound edges. Probe the wound with a sterile cotton swab applicator at all margins.
  • Undermining - look carefully for any skin that overhangs the wound's edges.
  • Drainage - is there drainage on the contact layers of the wound dressing? What does it look like (serous, purulent, bloody, green, yellow, clear, thick, etc.)? Is the drainage a breakdown of the wound dressing (like hydrocolloid) or actual drainage from the wound? Green drainage could indicate a pseudomonas involvement. Estimate the amount of drainage present.
  • Odor - is there any odor from the wound? This can offer a great deal of information about which organisms may be contaminating or infecting a wound. A "fruity" smell suggests staphylococcus organisms. Foul odor (fecal-like) indicates gram negative bacteria.
  • Necrotic tissue - what percentage of the wound appears to be necrotic tissue? Necrotic tissue is considered any tissue that is not "beefy" red and granular. Where is the necrotic tissue? Draw a small diagram or take a photograph from a closer range.
  • Granulation tissue - what percentage of the wound is granulating? Granulation tissue is healthy and bright,"beefy" red.
  • Infection - is the wound red (or streaking redness) or hot and swollen? Is there soreness out of proportion to what should be present given the patient's/resident's medical history and the progression and etiology of the wound? Infection should be assessed both clinically and with the help of lab data such as vitals and WBC count.
  • To classify foot ulcers, use the Wagner Classification System. Use"full thickness" or "partial thickness" phrasing to document other types of non-pressure ulcers.

The Wagner Classification System categorizes foot ulcers into six grades:

  • Grade 0 - Pre-ulcerative lesion, healed ulcers, presence of bony deformity.
  • Grade I - Superficial ulcer without subcutaneous tissue involvement.
  • Grade 2 - Penetration through the subcutaneous tissue (may expose bone, tendon, ligament or joint capsule).
  • Grade 3 - Osteitis, abscess or osteomyelitis.
  • Grade 4 - Gangrene of the forefoot.
  • Grade 5 - Gangrene of the entire foot.
    • Past treatment - note past treatments and any changes in product usage.This will help health care professionals new to the case, as wed as prevent the duplication of products that may not have produced the desired results.
    • Current treatment - document the types of irrigation, products and secondary dressings used during the current dressing change.
    • Be sure to sign the bottom of the note and date it.
    • Follow up with the appropriate doctor, nurse, therapist or health care professional to discuss your findings, especially if there is deterioration.

    Aggressive assessment and documentation is critical for the Improvement of wound treatment and healing. As the saying goes,"If you didn't document it, you didn't do it."

    The technological advances and new treatment options that are available arc important tools in the treatment process as well. And, of course, we can't forget the importance of patient education and preventative measures.

    Dr Tamara D. Fishman, BS, DPM, is a podiatric wound care consultant and President and CEO of the Wound Care Institute in North Miami Beach, FL (http.//www.woundcare.org).