[Standardized wound documentation of chronic wounds].
Owing to the long periods of treatment and multi-factoral etiology of chronic wounds, standardized wound documentation is necessary to enable judgement of the course of healing. We have developed a documentation system which permits a standardized assessment of chronic wounds by means of defined parameters and graded divisions. Besides containing the diagnostic and therapeutic measures which have been carried out, the documentation should also contain parameters of wound healing. These are the following: wound localisation, size of wound, degree of injury, infection, and wound morphology. Planimetry and photographic documentation complete the documentation. Thus a documented course of healing can be presented, which enables rapid retrospective analysis and, if needed, a change in therapeutic approach at an early stage. This complete, exact documentation is required by modern administration of justice and is a protection against the reversal of the onus of proof in lawsuits. The extent of documentation can be adapted to the individual needs of the institution responsible for treatment. However, a minimal amount of documentation should always include localisation of the wound, size, the diagnostic and therapeutic measures, and complications if any.
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Abteilung für Allgemeinchirurgie, Chirurgische Universitätsklinik Tübingen.
Coerper
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Witte
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Becker
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D002908:Chronic Disease; D017719:Diabetic Foot / Q000209:etiology / Q000601:surgery*; D004282:Documentation / Q000379:methods*; D005858:Germany; D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008501:Medical Records, Problem-Oriented; D011785:Quality Assurance, Health Care / Q000331:legislation & jurisprudence; D014945:Wound Healing / Q000502:physiology*
Die standardisierte Wunddokumentation chronischer Wunden.