Pressure Ulcers Documentation

For tracking the progress of the wound, modifying treatment as needed, and securing reimbursement from health care insurers, accurate documentation of a pressure ulcer is very important a nurse should do. To improve your documentation, here are the following tips:


• Measure from head-to-toe plane the length and from hip-to-hip plane the width.

• For consistency of ulcer measurements, establish landmarks. For example, imagine a clock face superimposed on the ulcer, with 12:00 in the direction of the patient's head.

• In the patient's chart, draw a baseline picture or include a baseline photograph of the ulcer. For photographic documentation, check your facility's policies and procedures.

• document the depth as <0.1 cm if the ulcer is superficial (the base is exposed but the ulcer isn't deep enough to measure).

• Ulcers deeper than 0.1 cm, measure it by placing a cotton-tipped applicator in the ulcer and measuring that against a centimeter ruler.

• Documentation should include
(1) the ulcer's anatomic location
(2) length, width, depth, and any tunneling or undermining in consistent units of measure, such as centimeters of the ulcer
(3) the drainage type, amount, odor, and color
(4) the color (ulcer or ulcer bed and ulcer margins)
(5) any erythema, induration, and/or maceration of the surrounding skin
(6) any tissue that are granulated or necrotic
(7) any pain related to pressure ulcer, ask the patient to determine, pain scale measurement, and finding for nonverbal indicators.