Good wound reporting makes clear at a glance what a wound looks like, what has been done and whether the care plan is working. That succeeds when the team agrees fixed elements and records them in the same way at every dressing.
Lack of clarity in wound care or reporting is one of the signals care organisations recognise most often. At the next dressing a colleague reads 'going well' and still does not know whether the wound is getting smaller. On this page you can read how to make wound reporting more concrete, without it taking more time.
A wound report is intended for the next colleague. They need to be able to compare it with the previous time. That calls for fixed elements:
Which descriptions and measuring methods you use follows from the agreements in your organisation.
Long stories hide the most important information. Write what you see and measure, and leave out interpretations as far as possible or label them as your assessment. A fixed order helps: first the observation, then the action, then the follow-up. Anyone used to a structure such as SOAP will recognise that layout. More on this can be found on SOAP reporting in healthcare.
The biggest gain lies in consistency. If three colleagues describe the same wound in three ways, progress cannot be followed. In an assignment on wound care and reporting I look at existing reports with the team, discuss what is missing and together we agree a fixed structure. I work with calm, overview and clear communication, so the team really adopts the new way of working.
Clear reporting makes it easier to adjust in time. So also record when the care plan is evaluated and by whom. How to agree the plan itself as a team is explained on agreeing a wound care protocol as a team.
I help with this through quality improvement and wound care and reporting. Want to know what that means for your organisation? Schedule an introduction.
Read three wound reports of the same client one after the other. If you cannot see the progress, you know where to start.
Usually not. A fixed structure actually makes writing faster, because colleagues do not have to think about what needs to go in.
Photos can support the description, provided your organisation has agreements on this, for example on consent and storage in the record.
Within the assignment and the agreements of your organisation I look at existing reports, to see together with the team what can be improved.
I am happy to drop by for a coffee to discuss your question.
Schedule an introduction ContactSchedule a meeting. I am happy to visit and discuss what I can do for your organisation.
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