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Wound Assessment and Documentation: Practical Guidance for Health Care Professionals

Wound healing begins with the assessment of the patient and the wound, and proper documentation by the health care provider. A comprehensive assessment is critical to understanding the factors that may have contributed to the wound's development and/or may impede wound healing. Appropriate and accurate documentation will help health care providers monitor a patient's progress toward healing, as well as support payment and help mitigate legal issues from improper or incomplete documentation.  

This guide contains articles from leading clinicians in the field of wound management offering practical guidance in the assessment of patients and their wounds.  

Wound Assessment and Documentation

Wound assessment requires a multifaceted approach; this guide includes information on a range of topics related to comprehensive evaluation of patients with wounds and tips for accurately documenting wound status: 

  • Approaches to patient assessment and history
  • Wound bed preparation basics
  • Assessment of wound characteristics for signs of barriers to healing
  • Identifying wound tissue and exudate types
  • Wound measurement and documentation strategies