Wound Care and Pressure Injury Documentation: Assessment, Treatment, and Monitoring

The Importance of Wound and Pressure Injury Documentation

Wounds and pressure injuries are among the most carefully scrutinized areas in aged care audits. Documentation must show that the facility identified at-risk residents, implemented prevention strategies, and if an injury occurred, provided appropriate assessment and treatment. Poor wound documentation can result in regulatory findings of non-compliance with the Aged Care Quality Standards and claims of neglect.

Strong wound and pressure injury documentation demonstrates clinical awareness, preventive care, and responsive treatment. It also provides continuity of care for the resident and supports the care team in making safe decisions about wound management.

Pressure Injury Risk Assessment and Prevention Documentation

Documentation begins before any wound appears. Facilities must show that they assess all residents for pressure injury risk and implement individualized prevention strategies.

• Risk Assessment Tool: Use a validated tool (e.g., Braden Scale, Waterlow) and document the score and date.
• Risk Factors Identified: Mobility limitations, incontinence, nutritional status, skin condition, age, medications, and any other factors increasing risk.
• Prevention Measures: Positioning schedule, pressure-relieving equipment (cushions, mattresses, beds), skin hygiene and moisturizing, nutrition and hydration support, incontinence management.
• Staff Education: Documentation that staff understand the person's risk and prevention plan.
• Monitoring: Regular skin checks (daily or more frequent if high risk) with documentation of findings.

Wound Assessment Documentation

When a wound is identified, assessment should document:

Location and Size:

• Specific body location (e.g., sacrum, left heel, right hip)
• Dimensions in centimeters (length, width, depth if applicable)
• Optional: photograph if facility policy allows

Appearance and Characteristics:

• Wound stage (for pressure ulcers: Stage 1, 2, 3, 4, or unstageable)
• Skin condition surrounding wound (redness, warmth, edema, maceration)
• Wound bed color and type (granulation, slough, eschar, necrotic tissue)
• Exudate amount (none, minimal, moderate, heavy) and type (serous, purulent, bloody)
• Odor (none, mild, strong)
• Signs of infection (increasing redness, warmth, purulent drainage, malodor)

Related Symptoms:

• Pain level and characteristics
• Bleeding or drainage
• Any surrounding skin breakdown or maceration

Contributing Factors:

• How did the wound occur (trauma, pressure, friction, shear)?
• How long has it been present?
• Any previous wounds in this location?

Wound Treatment Documentation

For each wound care intervention, document:

• Date and time of care
• Cleansing method: What was used to clean the wound?
• Dressing applied: Type, size, brand, any special properties (antimicrobial, absorptive, etc.)
• Topical treatments: Creams, gels, or medications applied and why
• Pain management: Was pain relief provided before or during care?
• Positioning: Any pressure-relieving measures used during healing
• Advice given: Any instructions given to the resident about care, activity restrictions, or nutrition

Example: Pressure Injury Documentation

Initial Discovery and Assessment (Day 1):

"16 March 2026, 10:00 AM. During morning wash, carer Priya discovered small red area on resident Michael's sacrum. Area approximately 2 cm diameter, non-blanching erythema (Stage 1 pressure ulcer), skin intact, warm to touch but no drainage or odor. Michael denies pain in area. RN Margaret assessed at 10:30 AM—confirmed Stage 1 PU, consistent with resident's high risk profile (limited mobility, recent weight loss, incontinence). Care plan reviewed: Michael is on 2-hourly repositioning but repositioning log shows missed one turn yesterday (staff shortage). Nutritional intake adequate. RN arranged wound assessment photo for comparison. Plan: Increase repositioning to every 1.5 hours, add foam mattress overlay, review incontinence management, and re-assess daily. Resident and family notified. Wound care plan initiated in care notes. GP notified and agrees with plan—no topical treatment needed at Stage 1."

Progress Note (Day 5):

"20 March 2026, 10:00 AM. Sacral area remains Stage 1. Erythema less pronounced than on 16 March (improvement noted). Skin integrity intact, no new redness. Repositioning log shows 100% compliance past 4 days. Michael now on regular nutritional supplement. Weight stable. Pain: None. Mattress overlay in place and effective. Continue current plan—1.5-hourly turns, mattress, nutrition support. Wound check to continue daily. No changes needed at this time."

Monitoring and Reassessment

Ongoing wound documentation should include:

• Regular assessment: How often and by whom is the wound being assessed?
• Changes in wound status: Improving, stable, or deteriorating?
• Effectiveness of treatment: Is the current dressing/treatment working?
• Resident tolerance: Pain, discomfort, or complications?
• Changes in prevention measures: Are repositioning, padding, or nutrition strategies being maintained?
• When to escalate: If a wound is worsening, deepening, showing signs of infection, or causing pain, document escalation to RN or GP

Infection and Complications Documentation

If signs of infection develop, document immediately:

• Increased redness, warmth, or swelling around wound
• Change in drainage (color, smell, amount)
• Fever or systemic signs of illness
• Pain increase
• Actions taken (RN review, GP contact, swab for culture, antibiotics prescribed)

Common Documentation Gaps

• Vague descriptions: "Pressure area on bottom" is not helpful. Be specific about location, stage, and measurements.
• Missing prevention evidence: If a pressure injury develops, documentation should show what prevention measures were in place before it occurred.
• No timeline: When was the wound first noticed? How long has it been present? Progression over time is important.
• Incomplete treatment records: What dressing was used? For how long? Was it effective?
• Missing GP involvement: If a pressure injury worsens or becomes infected, the GP should be notified and this should be documented.
• No resident/family communication: Were they informed of the wound and the plan? This should be documented.

Conclusion

Comprehensive wound and pressure injury documentation demonstrates that the facility is proactive in prevention, responsive to identified wounds, and committed to healing and comfort. This protects both the resident and the facility, and supports compliance with aged care standards. For detailed clinical guidance, consult the Australian and New Zealand Wound Society guidelines. Modern documentation systems can help track wound assessments and ensure consistent monitoring and escalation.

Protect Your Residents and Your Facility

Pressure injuries are a high-risk area in audits—but strong documentation demonstrates your preventive approach and responsive care. AccuNote's system helps track wound assessments, monitor healing progress, and ensure nothing gets missed. Schedule a free consultation to see how our documentation system supports better wound care outcomes—or start your free 14-day trial today.

This article was written by AccuNote's Wound Care Specialist Team, experienced in pressure injury prevention, assessment, treatment documentation, and clinical continuity in aged and disability care settings.