Documentation and Evaluation of Wound Care

• Documentation and evaluation of wound care are vital for monitoring the progress of wound healing, identifying complications or delays in healing, adjusting the plan of care as needed, communicating with other health care providers, and ensuring quality of care
• Documentation of wound care should include the date and time of assessment and intervention; the type, size, shape, location, stage, exudate, odor,

               - necrosis, edges/margins/surrounding skin of the wound;                              the type,

               - size/amount/frequency/change/application/removal of dressing;                   the patient's response to intervention; any problems or                                 complications; any teaching or referrals; and any other relevant                   information

• Evaluation of wound care should include comparing the current status of the wound with previous assessments; determining if the goals and outcomes are met; identifying any factors that may affect healing; modifying the plan of care as indicated; and documenting the evaluation findings