Byram Healthcare

Wound Documentation

Feature	Documentation possibilities	Interpretation
Color	Red Pink Purple Black/brown Yellow Gray Green White	Healthy blood flow Poor blood flow, anemia Engorged, edema, trauma, bioburden Non-viable tissues Non-viable tissues, possible dermatitis Non-viable tissues Infection, non-viable tissues Ischemia, maceration
Granulation	Present – red, beefy Protruding above surrounding skin	Note presence, increases, decreases; Excessive granulation
Necrotic tissue	Slough – yellow Eschar – black/brown	Desiccation, dehydration

First though, it’s important to know how wounds are documented. The appearance of the wound is documented according to size, color, infection, and the phase or appearance of granulation, necrotic tissue, exudate, and periwound areas. Documentation is completed according to routine protocols, which may be more often in acute care settings and at dressing changes in other care settings. Progress in healing is part of the documentation and trouble-shooting process for the success of care planning. Color of the wound may indicate blood flow, edema, infection, and the viability of tissues. The presence or absence of granulation and changes in granulation over time can indicate the progression of wound healing.

Feature	Documentation possibilities	Interpretation
Exudate	Red Green/blue Clear/yellow Odorous Also consistency: Viscous Serous - clear/yellow (non-draining) Dry/crusted	Bleeding Infection Infection and/or lymph involvement and/or normal drainage Infection
Periwound area	Symmetrical Ragged Erythema/induration Warmth Maceration	Diabetic and arterial damage ulcers Venous stasis ulcers Possible infection Overhydration, moisture causes Dependent (gravity) and infection edema
Other features	Undermining Tunneling	Tissue loss under edge of wound Tissue loss at any point in wound

Exudate color and consistency give clues about the presence of infection, blood flow, and viability of tissues. Odor and color of exudate can also indicate infection. The area around the wound is documented for color, edema, warmth, maceration, and wound edges. Exudate in various colors can mean infection, and the area around the wound are to be noted for color as well. Other features of the wound include the presence of of the sinus tract. Undermining is damage to tissues that are directly under intact skin along the edge of the wound. Tunneling is a dead space that may go in any direction from the wound bed. There is a high risk for infection in these wound features. The documentation includes the location and greatest depth of the undermining or sinus tract according to clock hands, where 12 is closest to the head and 6 is closest to the foot.