Documenting wound care for pressure ulcers

The trend toward documenting functional outcomes rather than simply describing impairments has been an especially difficult transition for clinicians caring for older adults with wound conditions. Functional outcomes achieved through skilled wound care are greatly influenced by a disciplined decision-making process and the clinician's ability to commit to a plan of care. Documentation is the reflection of this thought process. Documentation may be enhanced by blending concepts inherent to the physiology of normal wound healing with clinical rationale for selected interventions. Once practiced, these principles will greatly assist the clinician to document clearer justification for skilled wound care services and demonstrate positive functional outcomes.