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Wound Reporting Guidelines

Decubitus ulcers, also known as pressure sores or bed sores, are wounds that occur due to excess pressure on the skin. They usually occur over bony areas such as the hips, coccyx, heels, and elbows. There are several factors that can lead to these wounds, including improper nutrition and immobility. When wounds occur, it is important to report them in the patient's chart and notify his/her doctor so that proper treatment and care can be received.

  1. When to Report Wounds

    • Any time a wound or injury occurs to a patient it should be reported to the correct authorities. All wounds that are discovered, no matter what the cause or location, should be reported immediately after they are found. When the wound is discovered it should be properly documented in the patient's chart and a wound report should be filed. Wound reports are important because they ensure wounds are treated properly and monitored for healing or deterioration.

    Who to Report Wounds to

    • All wounds should be reported to the patient's health care provider and documented. When a wound is discovered the patient's care giver, such as a nurse, therapist, or doctor, should be notified immediately. Health care providers who are aware of the wound can implement certain precautions to initiate healing and prevent the wound from becoming worse. Wounds should also be reported to state health departments or social services if abuse or neglect is suspected.

    Classification of Wounds

    • Wounds (pressure ulcers) are classified by stages of development. Reporting wounds when found at the early stages of development may help to prevent the wound from getting worse and can assure the patient receives immediate treatment, which is important for healing. Stage 1 wounds, which are the least severe, are areas of the skin that stay red even after pressure has been relieved. They do not include a break in the skin. Stage 2 wounds occur when partial thickness is lost resulting in a wound which opens up and appears as an abrasion or blister. Stage 3 wounds occur when full thickness is lost and subcutaneous tissue is exposed, often appearing as a deep hole that may or may not affect adjacent tissue. Stage 4 wounds, which are the most severe, occur when full thickness is lost and exposure of muscle and/or bone tissue is present.

    Writing the Wound Report

    • Documenting a wound is important because it allows the patient's health care providers to keep track of the wound and its progress. When writing wound reports, make sure to include accurate and detailed information pertaining to the wound. Include the size, location(s), stage, time and date the wound was discovered, and the name of the person who discovered it. When determining the size of the wound, measure the length, width, and depth. Also document efforts to prevent the wound from getting worse and all treatments provided.

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