Record the date and time of initial and subsequent treatments. State the initial treatment. Detail preventive strategies performed, then document the wound's anatomic location and size (length, width, and depth); color and appearance of the wound; amount, odor, color, and consistency of drainage; and condition of the surrounding skin. It is important to reassess the wound at each dressing change or according to the recommendations of the placement. Photography may be part of pressure ulcer assessment in facilities where it's available and with patient consent. Ttis helps to note improvements Consistent methodology in obtaining the photograph is important (such as documenting the distance from which the photograph was taken). Capture patient identification, date the photograph was taken, and wound location on the photograph for documentation purposes.
Update the patient's care plan, as required. On the clinical record, note changes in the condition or size of the wound and elevations of skin temperature. Document when and who was notified of pertinent abnormal observations. Record the patient's temperature on a graph to allow easy assessment of body temperature patterns.