Accurate documentation of skin tears helps in appropriate management decisions, evaluation of the healing process, and support for reimbursement claims.

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How to
Document
Skin Tears
Accurate documentation of skin tears helps in appropriate
management decisions, evaluation of the healing process,
and support for reimbursement claims.
WoundWizard®
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Yonkers, NY 10704

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Skin tears occur when the skin or dermis begins to separate from
itself. These tears are a painful experience that can lead to
infection if the damaged area is left untreated. They can be the
result of a wide variety of injuries. They appear to be a mere
minor cut; however, they are often more complex wounds
because they can happen under the surface of the skin. In fact,
skin tears can occur on any anatomical location. In older people,
they are often sustained on the extremities such as the upper and
lower limb, and on the dorsal aspect of the hands and in case of
neonates with immature skin, they occur on the head, face and
extremities. However, patients who are elderly or dependent on
others have a higher risk for developing skin tears. This is
because aging promotes skin fragility, so even the simplest
bump or knock can cause tissue damage. Patients who are very
young and have immature skin, or those who are critically ill
and/or have multiple risk factors are also vulnerable.
The risk factors associated with skin tears are falls, blunt trauma,
mishandling equipment and poor nutrition. Other risk factors
include age and gender; history of previous skin tears; dry,
fragile skin; medications that thin the skin such as steroids;

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echymoses; impaired mobility or vision; cognitive or sensory
impairment; co-morbidities that compromise vascularity and
skin status, including chronic heart disease, renal failure,
cerebral vascular accident and dependence on others for
showering, dressing or transferring.
Documenting Skin Tears
All the information regarding the skin tear should be carefully
documented and the documentation should be clear, concise and
legible. Wound care documentation plays a vital part in
monitoring, treating and managing wounds. It communicates the
information about the care healthcare providers give and the
status of the patient to the rest of the healthcare team to help
ensure quality and continuity of care. The initial assessment of
the wound should include a comprehensive assessment of the
patient and his/her wound. Patient’s age and medical history,
any underlying co-morbidities and general health status should
be determined, which is important for wound healing.
Assessment must establish the cause of injury including when,
where and how it occurred. In addition to that, the following
details should be documented.

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➢ Anatomic location and duration of the tear
➢ Dimensions of the tear (length, width, and depth)
➢ Wound bed characteristics and percentage of viable vs.
nonviable tissue
➢ Type and amount of exudate
➢ Presence of bleeding or hematoma
➢ Periwound skin color and condition, note edema,
maceration, and induration
➢ Wound-edge approximation and condition (open vs.
closed)
➢ Degree of flap necrosis
➢ Integrity of surrounding skin
➢ Signs and symptoms of infection
➢ Associated pain
There are several modern technologies available to improve
wound documentation, wound care EHR is one such system

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designed to overcome the obstacles healthcare providers might
encounter during the normal course of documenting. They are
user-friendly, cloud-based, and extremely mobile, created with
extensive pre-populated dropdown windows, clean,
straightforward design, and are compliant with HIPAA.