Drainage type and amount should be documented to show medical necessity for treatment and supplies. The types range from serous (thin, watery, clear), to foul purulent (thick opaque-yellow to green with offensive odor). Amount ranges from none or scant to minimal, moderate, and large. Wound odor, if any, should also be described after the wound is cleansed according to specific descriptors. There is standard nomenclature for documenting the amount of wound drainage.

This includes:

None or dry

Scant with moist wound tissues, but no measurable drainage

Small with very moist wound tissues and drainage covering 25% of the dressing in 24 hours

Moderate with wet wound tissues and drainage covering 25%-75% of the dressing in 24 hours

Large with fluid-filled wounds and more than 75% of the dressing covered in drainage in 24 hours

Types of Wounds

Sanguineous, which appears as thin moisture that is bright and red

Serosanguineous, which appears as thin moisture that is watery and pale red to pink

Serous, which appears as thin moisture that is watery and clear

Purulent, which is thick or thin moisture that is opaque tan to yellow

Foul purulent, which is thick moisture and opaque yellow to green, and has an offensive odor

The method of debridement requires documentation to determine medical necessity. Types include autolytic, enzymatic, mechanical, or surgical.

Wound Bed

The wound bed can be described with the type of wound bed tissue, adherence of the tissue, and the amount of the wound bed covered by the tissue. Wound bed characteristics can be described as non-, loosely-, or firmly-adherent according to how easily the wound bed separates from the wound base. The amount of tissue and type of tissue should also be described. Tissue types include epithelial, granulation, slough, eschar, and any foreign bodies.

Epithelial tissue may be the regeneration of epidermis over a partial thickness wound. Scar tissue over a full thickness wound is called epithelialization.

Granulation tissue forms in the proliferative phase before epithelial cells resurface the wound bed. There can be healthy granulation tissue that generally appears as pink or red, or unhealthy granulation which is dark, dusky red, bleeds easily, and may be an indication of infection. Hypergranulation is when there is excess granulation that appears above the normal wound bed surface.

Slough is non-viable tissue that can be fibrinous, adherent, stringy, or thickened with colors ranging from yellow and green to gray, brown, or tan. This type of tissue increases risk for infection and is a barrier to healing. In this case, debridement to expose viable tissue may expedite the healing process.

Eschar is the dead tissue seen in full-thickness wounds. While the blood flow in tissue under eschar is usually poor and the wound may be at higher risk for infection, the eschar itself may also act as a barrier to wound infection. Guidelines suggest that as long as the eschar on the patient’s heels is dry, adherent, and intact, it should not be removed. However, when it becomes wet, draining, loose, and/or red, it is an indication for the need of debridement.

There may be foreign bodies in the wound bed, which may require removal. However, there can be complications, such as enlarging the wound, creating another wound, and infection.

Tissues may be categorized as non-adherent, loosely adherent, or firmly adherent.

The amount of the wound bed covered should be documented. For example, documentation might note that 50% of the wound bed is covered in soft yellow slough, or 50% of the wound bed is beefy red granulation tissue.

Wound edge characteristics should be described according to their definition (well defined or undefined), attachment (attached or unattached), epibole (rolled edges), maceration, and whether it is callused or fibrotic. The border shape may also be described.