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Get the free How to document wounds and bruises - Emergency Department

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On the chart below, use an X to mark bruises, cuts, painful or ticklish areas to avoid during your massage. Circle areas of tension, and those needing extra work. Image 2000 Health eon/WebMDCorporation
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How to fill out how to document wounds

01
Start by cleaning the wound with mild soap and water.
02
Use a sterile gauze pad to gently dry the area around the wound.
03
Apply an antibiotic ointment to prevent infection.
04
Cover the wound with a sterile adhesive bandage or dressing.
05
Change the bandage or dressing daily or as directed by a healthcare professional.
06
Keep an eye on the wound for any signs of infection, such as increased redness, swelling, or pus.
07
If the wound does not show signs of improvement or if you are unsure how to properly care for it, seek medical attention.

Who needs how to document wounds?

01
Anyone who has suffered a cut, scrape, or abrasion may need to document wounds to ensure proper care and healing.
02
Medical professionals, such as doctors or nurses, may also need to document wounds for accurate medical records and treatment plans.
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Documenting wounds involves recording details about the wound's characteristics, treatment, and healing process to ensure proper patient care.
Healthcare professionals involved in patient care, including nurses and physicians, are required to document wounds.
To fill out the documentation, provide specific information about the wound type, size, location, color, drainage, pain level, and any treatments administered.
The purpose is to track the healing progress, provide a clear treatment history, and ensure effective communication among healthcare providers.
Information such as wound assessment findings, treatment details, patient responses, and follow-up plans must be reported.
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