How to Write Documentation on Skin Lesions for Nurses

Wounds, lesions or ulcers are frequently seen in patients in nursing homes and hospitals. These wounds occur from pressure ulcers or skin tears or as a result of traumatic injury. Nurses provide wound care for these patients, and these interventions must be documented. In addition, detailed descriptions of the wound are included to assess whether treatment is effective. There are several important pieces of information that should be included with wound documentation.

Things You'll Need

• Measuring tape
• Sterile cotton swab

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Instructions

• 1

  Describe the exact area and location where the wound is located.

• 2

  Measure the length (vertically) of the wound at its longest point. Measure the width (horizontally) of the wound and record these numbers. This information will be used to determine whether the wound is growing or getting smaller over time.

• 3

  Place the cotton end of the swab into the deepest area of the wound. Make a mark on the stick at the level of the skin. Measure this distance and document the depth of the wound in your notes.

• 4

  Describe the tissue (i.e., granulating, yellow, eschar) in the wound bed, as well as any drainage or odor. Different areas of the wound may contain different types of tissue. Sketch the wound in your notes and label the areas appropriately.

• 5

  Document specific treatment provided during the wound care process, including the removal of dead tissue, any topical medications applied and dressings that are used.