Wound Measurement & Documentation Guide

Measuring Wounds Measure the length "head-to-toe" at the longest point (A). Measure the width side-to-side at the widest point (B) that is perpendicular to the length, forming a "+". Measure the depth (C) at the deepest point of the wound. All measures should be in centimeters.

A B

C

CM12345 6 sample7 89 10 11 12 13 14 15

This ruler is intended for use as a reference only. To prevent infection, do not use this ruler to measure an actual wound. Tunneling/Sinus Tract

A narrow channel or passage- Using a clock format, way extending in any direction describe the location from the base of the wound. and extent of tunnel- This results in dead space with ing (sinus tract) and/or a potential risk for abscess undermining. formation.

12 Undermining 9 3 Open area extending under intact skin along the edge of the wound.

6

The head of the patient is 12:00, the patient's foot is 6:00.

If the wound has many landmarks, you may want to trace it before measuring.

Portions of this material were prepared by Primaris Healthcare Business Solutions. It is provided by Health Quality Innovators (HQI), the Medicare Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. HQI/11SOW/8/22/2016/2556 Wound Measurement & Documentation Guide

Pressure Ulcer Documentation

Wound Location: • Designate left, right, top, bottom, side, front, middle, etc., as appropriate (for example, inner left knee) • Describe anatomical location according to your facility practice; abdomen, knee, coccyx, sacrum, trochanter (hip), ischial tuberosity (buttock), calca- neus (heel), malleolus (ankle), etc. Be specific! Location description should direct staff to exact area for treatment.

Stage: I, II, III, IV, suspected deep tissue injury (sDTI), unstageable

• Necrotic Tissue Size: » Slough - thin stringy consistency; L x W x D yellow, gray, white, green, brown • Length (head-to-toe) » Eschar - thick hard consistency; • Width (hip-to-hip) brown to black • Depth (deepest point) » Adherency - Non-adherent, loosely adherent, firmly adherent Exudate/Drainage: • Tunneling/Sinus Tract (use clock to designate location) Amount • Undermining (use clock to designate • None, dry, scant, moist, small, medium, location) large, copious Color Surrounding Tissue: • Serous (thin, watery, clear) • Sanguineous (thin, bright red) • Color (red, pink, pallor, purple, normal • Serosanguineous (thin, watery, pale red to skin tones) pink) • Edema; pitting, non-pitting • Purulent (thick or thin, opaque to tan to • Firmness yellow or green) • Temperature Odor • Tissue Characteristics: intact, macerated, • None, foul, pungent, fecal, musty, sweet rash, excoriated, etc.

Wound Edges: Pain Assessment: • Border shape; irregular, round, oblong, • Rate on scale of 1-10 before, during and etc. after treatment; episodic or chronic • Edges attached/unattached; undermining • Interventions for pain • Rolled under (epibole) • Callused Wound Progress: • Improving, deteriorating, no change Wound Base: • Interventions in place; pillows, low air • Granulation (beefy red, bubbly in loss beds, special devices, nutritional appearance) supplements, etc. • Epithelialization (light to deep pink, pearly • Continued treatment or notify MD and light pink; may form islands in the wound responsible party of need for change bed)