Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation of Expected Findings
3 cm x 2 cm Stage 3 pressure injury on the patient’s sacrum. Dark pink wound base with no signs of infection. Cleansed with normal saline spray and hydrocolloid dressing applied.
Sample Documentation of Unexpected Findings
3 cm x 2 cm x 1 cm Stage 3 pressure injury on sacrum. Wound base dark red with yellow-green drainage present. Removed 4 x 4 dressing has 5 cm diameter ring of drainage present. Periwound skin red, warm, tender to palpation. Temperature 36.8⁰ C. Dr. Smith notified of all the above. Wound culture order received. Wound cleansed with normal saline spray, wound culture collected, hydrocolloid dressing applied.
