Wound Assessment, Measurement, and Documentation
A repeatable assessment
Assess every wound the same way: anatomic location, etiology, stage or classification, measurements, wound bed tissue (percent granulation, slough, eschar, epithelial), edges, periwound skin, exudate (amount, color, consistency, odor), pain, undermining and tunneling, and signs of infection. Include perfusion (pulses, capillary refill, hair distribution, ABI or toe pressure) and sensation (10-g monofilament). Document undermining and tunneling by clock face plus depth in centimeters, with 12 o'clock pointing toward the patient's head.
Measuring correctly
Use a disposable centimeter ruler. Measure the longest length along the head-to-toe axis, the widest width perpendicular to that length, and probe depth at the deepest point with a cotton swab. Record consistently as length x width x depth in centimeters and repeat at the same interval (weekly, and with any change). Photograph with consent, a patient identifier, a scale, and consistent lighting.
Documentation
Write objective, measurable findings, not "wound looks better." Note who measured, the method, and the plan. Good documentation supports continuity of care, quality reporting, and medical necessity for debridement, dressings, and support surfaces.
Traps
- Mixing units or measuring width without perpendicularity.
- Recording undermining as a linear wound dimension.
- Calling a wound "healing" while documenting increased size, slough, or exudate.
- Using a single dimension on an irregular wound.
- Failing to reassess after a change in condition or dressing.
Rule of thumb
Biggest by biggest, then deepest. A wound 4.0 cm long by 2.5 cm wide with 1.2 cm of undermining from 2 to 5 o'clock is documented exactly that way: length first, width second, then depth and undermining with clock positions.