Wound documentation is important for clarity and to avoid misunderstanding. Location should use correct anatomical terminology like dorsal vs. plantar on the foot. Size is measured in centimeters with length, width, and depth. Photography can support written documentation if institutional policy is followed, using a measuring device and macro mode for close-up shots without distortion.

1. Wound Documentation,
Anatomy & Photography
THE BASICS

2. Wound documentation
Location
Use Correct Anatomical Terminology
More specificity leads to greater clarity and less chance
for misunderstanding
Dorsal/Plantar vs. top/bottom of the foot
Also important for Debriding – Know what you’re
debriding and what structures are in the area

3. Location

4. Anatomy
Anatomy: Anatomy is the branch
of biology concerned with the
study of the structure of organisms
and their parts
Anatomical position: The
erect position of the body with the
face directed forward, the arms at
the side, and the palms of the
hands facing forward

5. Terminology
Anatomical Planes
 Median – vertical plane passing longitudinally
through body from front to back, dividing into Lt
& Rt halves
 Sagittal – vertical plane passing through body
parallel to median plane
 Coronal/frontal – vertical plane at right angle
to median, dividing body into anterior &
posterior portions
 Horizontal/Transverse – horizontal plane
passing through body at right angles to median
& coronal planes

6. Terminology
Directional Terminology
 Superior (Cranial) – Nearer to the Head
 Inferior (Caudal) – Nearer to the Feet
 Anterior (Ventral) – Nearer to the Front
 Posterior ( Dorsal) – Nearer to the Back
 Medial – Nearer to the Median Plane
 Lateral – Farther from the Median Plane

7. Terminology
Directional Terminology
 Proximal – nearer to the trunk or point
of origin
 Distal – farther from the trunk or point
of origin
 Superficial – nearer to or on the surface
 Deep – further from the surface
 Ipsilateral – on the same side of the
body
 Contralateral – on the opposite side of
the body

8. Surface Anatomy
 Surface anatomy (AKA superficial anatomy or visual anatomy) is the
study of the external features of the body.
 In the case of human surface anatomy, these are the form and
proportions of the human body and the surface landmarks which
correspond to deeper structures hidden from view.
 Most of the bones of the skeleton are palpable and provide landmarks
for locating other anatomical structures.
 The effectiveness of visual inspection and palpation in studying a
person's surface anatomy is influenced by the thickness of the
hypodermis, which varies in accordance with the amount of
subcutaneous adipose tissue.

9. Surface Anatomy
Abdomen
 Two commonly used clinical methods
of dividing the abdomen for descriptive
purposes:
 First – General Localization
Divided into 4 quadrants
Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)

10. Surface Anatomy
Abdomen

11. Surface Anatomy
Abdomen
 Second method is used for
specific localization
Includes
Epigastric
Umbilical
Hypogastric
R/L hypochondriac
R/L lumbar
R/L iliac

12. Surface Anatomy
Abdomen

13. Surface Anatomy
Posterior Torso/
Buttocks/Hip region
 Important to correctly identify
location and bony prominences
 Hip vs buttock vs thigh
 Know the location of the bony
prominences & how to
palpate/identify

14. Regional
Anatomical Terms
 Important to be able to
identify and accurately label
the wound based on generally
accepted anatomical
terminology
 Also important to be able
to understand and
communicate w/
physicians
 Helpful if notes used in
legal situation for terms to
be correct/standard

15. Wound documentation
Size
Measure in centimeters
Measure Length x Width x Depth
Document using the “Clock System” with head = 1200
Length = head to toe direction; 1200 - 0600
Width = hip to hip direction; 0300 - 0900
Depth = measure deepest part of visible wound bed

16. Size

17. Wound documentation
Document any undermining/
tunneling/sinus tracts
Tunneling- narrow opening or path extending from
wound through underlying tissue
Undermining – tissue destruction underlying intact skin
along wound margins
Sinus Tract – blind opening or path that extends from
open wound and dead ends in subcutaneous tissues

18. Wound documentation
Describe drainage/exudate
Type
Sanguineous – thin, bright red (bloody)
Serosanguineous – thin, watery, pale red to pink
Serous – thin, watery, clear, pale yellow
Purulent – thick or thin, can be green, brown, yellow

19. Wound documentation
Describe drainage/exudate cont.
Amount
None
Scant – wound moist, little to no drainage on dressing
Small/Minimal – wound moist, exudate 25% or less of
dressing
Moderate – wound moist to wet, exudate up to 50% of
dressing
Large/Copious – wound wet, exudate > 50% of dressing

20. Wound documentation
Describe the odor
Describe presence or absence of odor
Strong
Foul
Pungent
Fecal
Musty
Sweet

21. Wound documentation
Tissue Types
Slough – usually lighter in color, thinner and stringy in
consistency
Color – Can be yellow, gray, white, green, brown
Eschar – usually darker in color, thicker and hard
consistency
Color – black/brown

22. Wound documentation
Tissue Types cont.
Granulation Tissue – it is usually beefy red, granular,
bubbly in appearance
should be differentiated from a smooth red wound
bed
Color – red, pink, pale pink or full dusky red
Epithelialization – can appear as deep pink, then progress
to pearly
***Important to understand that Partial thickness wounds
will not have eschar/slough/granulation***

23. Tissue Type

24. Wound documentation
Wound Margins/Borders/Edges
Regular
Irregular
Not Attached
Rolled/Epibole
Callous

25. Wound borders

26. Wound documentation
Periwound Assessment
Color
Edema
Firmness
Intact
Induration
Pallor

27. Wound documentation
Periwound Assessment cont.
Lesions
Texture
Evidence of previous scarring
Rash
Staining
Moisture/Maceration

28. Wound documentation
Signs of Infection
Fever
Streaking
Redness
Increased drainage
Odor
Warmth
Elevated WBC

29. Wound documentation
Signs of Infection
Induration
Malaise
Edema
Weeping
Increased pain
Discoloration

30. Wound documentation
Photography
First – Know what your institutional policy is & follow it
HIPPA
Patient Dignity/Privacy issues
Use of Digital vs. Film vs. Cell phone
Follow policy of institution
Use of flash is controversial – use as per policy

31. Wound documentation
Photography
Use to support written documentation
Good to take photos pre & post debridement as adjunct
to written documentation
Follow policy on the storage and use of the photos

32. Wound documentation
Photography
Always have some kind of measuring device in photo
Adjacent to wound, same plane
Parallel to wound bed
Avoid wound distortion
Use MACRO mode on camera if available – allows for
closer image in focus
Clean area of clutter before taking photo