Documentation/Wound Care
Module guide · Clinical
Wound Care
Document a wound the way a WOCN (Wound, Ostomy and Continence Nurse) would: type, stage, measurements and wound bed characteristics, then track dressing changes, debridement, and healing photos over time, and refer to dermatology when needed.
What this module is for
Every screen is open to the same broad set of clinical roles, there's no nurse-only versus physician-only split here, unlike some other modules.
Who uses it
Nurses, physicians, NPs and PAs, charge nurses, homecare coordinators, home health aides, and directors can all reach every screen and perform every action described below.
Where to find it
Open Wound Care from the sidebar. Seven screens: a dashboard, Patient Search, a per-patient Wound Record, New Assessment, Assessment tracking, and dermatology Consults (new referral + queue).
- 1
Find the patient
Search by name or MRN to open their wound care record.
- 2
Document the wound
Record type, NPUAP/EPUAP stage, measurements, and wound bed characteristics in a new assessment.
- 3
Track it over time
Log dressing changes and debridement, and upload photos to document healing progression.
- 4
Refer or close
Send a dermatology consult referral if needed; close the wound once it's healed.
A few terms you'll see throughout
Dashboard
A landing page: search for a patient, and see dermatology consults still waiting for triage.
A Pending Consults stat card shows the count awaiting dermatology review, with up to six rows listed below it (patient, referral reason, requested date, a PENDING badge); View All opens the full queue. Two nav cards, Patient Search and Pending Consults, jump into the module's two sub-areas.
Patient search & wound record
Search finds a patient by name or MRN; their record shows active wounds, full wound history, and consult history in three tabs.
From the patient record, New Wound Assessment and New Dermatology Consult buttons start the two workflows below. Three tabs:
Patient record tabs
| Field | What it means |
|---|---|
| Active Wounds | Default tab; only currently-open wounds. |
| All Wounds | Full history, each card additionally tagged Active or Closed. |
| Consults | Every dermatology referral made for this patient, any status. |
Each wound card shows anatomical location, wound type, stage (if a pressure injury), measurements and computed area, exudate, tissue bed, periwound skin condition, and INFECTION / ODOR badges when flagged. Each consult card shows its status and, once completed, the diagnosis, findings, and treatment plan.
Pending — referral made, not yet triaged
Scheduled — dermatology appointment booked
Completed — consult finished, findings on file
Cancelled — referral called off
New wound assessment
A full clinical intake form, reached from a patient's record. Requires a patient already selected.
Wound identification & staging
| Field | What it means |
|---|---|
| Wound Number, Encounter | Both optional. |
| Wound Type | Pressure Injury, Surgical Wound, Diabetic Ulcer, Venous Ulcer, Arterial Ulcer, Traumatic Wound, Burn, Skin Tear, Dermatologic Lesion, or Other. |
| Anatomical Location* | Free text, e.g. "Left heel, Sacrum." |
| Pressure Injury Stage | Stage 1 (Non-blanchable erythema) through Stage 4 (Full thickness tissue loss), Unstageable, Deep Tissue Pressure Injury, or N/A for non-pressure wounds. |
Measurements (cm) & wound bed characteristics
| Field | What it means |
|---|---|
| Length, Width, Depth | Numeric, optional; area is calculated automatically once saved. |
| Exudate Amount | None, Scant, Minimal, Moderate, or Heavy. |
| Exudate Type | Serous, Sanguineous, Serosanguineous, Purulent, or Fibrinous. |
| Tissue Bed | Granulation, Slough, Eschar, Epithelial, Necrotic, or Mixed. |
| Periwound Skin | Intact, Macerated, Erythematous, Indurated, Denuded, or Edematous. |
| Odor present, Infection suspected | Checkboxes; the Infection box highlights amber once checked. |
| Assessed By* | Staff search. |
| Assessed At | Defaults to the current date/time. |
Saving opens the new assessment's tracking page directly.
Tracking a wound
Each assessment has its own page with three tabs: a read-only overview, a treatment log, and photo documentation.
Tabs
| Field | What it means |
|---|---|
| Overview | All the intake fields, plus who assessed it and when, read-only. |
| Treatments | A dated log of dressing changes and debridement; "Record Treatment" adds an entry. |
| Photos | Upload and browse progression photos. |
"Record Treatment" form
| Field | What it means |
|---|---|
| Treated At | Defaults to now. |
| Primary Dressing, Secondary Dressing, Cleansing Agent | Free text. |
| Debridement performed | Checkbox; reveals a required Debridement Type (Sharp, Autolytic, Enzymatic, Mechanical, Biological, or Surgical). |
| Negative pressure wound therapy (NPWT) | Checkbox. |
| Treatment Notes, Next Dressing Date | |
| Performed By* | Staff search. |
On the Photos tab, pick an angle/view label and optional notes, then choose a photo, it uploads immediately, no separate submit step. Thumbnails open a full preview with timestamp and notes.
Closing a wound has no undo
Dermatology consults
Refer a patient to dermatology, and work the triage queue.
New referral
Patient (required) and Referral Reason (required, free text) are the only must-haves; Encounter, Dermatologist, and Requested Date are optional. Launched from a patient's record, or standalone with a manual patient search.
Pending queue
Lists referrals still awaiting triage only, completed and cancelled consults live on the patient's own record instead. Complete Consult records Findings, Diagnosis, and Treatment Plan, none required, and removes it from this queue.
There's no button to move a referral to Scheduled or Cancelled from this screen, those statuses exist in the system but aren't set through the UI.
Good practices
Use the wound bed fields even when they feel repetitive
Photograph consistently
Double-check before closing a wound