Wound documentation is crucial from a legal and clinical standpoint. On admission, patients should receive a comprehensive assessment with appropriate documentation of any skin concerns. Ongoing assessment and documentation allows clinicians to determine if interventions are effective for the treatment/management of existing wounds. Although there are a variety of wound assessment tools to describe the status of wounds, many tools and classification systems lack validity, reliability, responsiveness to change, and feasibility to be used at point of care. For example, the differentiation between a Stage 1 pressure ulcer, deep tissue injury, and moisture-associated skin lesions remain elusive, especially for novice clinicians.
Confusion has also been created surrounding assessment of different wound tissue types based on color. For instance, whether yellow tissue is slough, fibrin, layers of exudate, and adipose tissue is not always that straightforward. Assessment is susceptible to error and subjective interpretation such as descriptions of the extent of localized swelling, maceration, and periwound redness.
Wound photography provides an objective approach to wound documentation. The February CME article in Advances in Skin & Wound Care highlights the merit and pitfalls for using wound photography. To obtain a satisfactory and clear image, clinicians must be trained to take close-up pictures using the macro mode and flashes. Policies should be developed to ensure that patients are informed of the purpose of photography, necessary consents are obtained, and images are stored appropriate area of health records.