After performing a sterile dressing change on a patient's right lower leg wound, a medical assistant is documenting the wound assessment in the chart. Which entry BEST reflects appropriate documentation of wound characteristics?
- ARight lower leg wound, looks much better today, healing well, dressing changed without difficulty.
- BRight lower leg wound, small and shallow, with a small amount of yellow fluid and surrounding redness, dressing reinforced.
- CRight lateral lower leg wound, measures 3 cm by 2 cm with 0.4 cm depth, wound bed 80 percent red granulation and 20 percent yellow slough, scant serosanguineous drainage, peri-wound skin intact and pink. Correct
- DRight lower leg wound, 3 by 2, bloody drainage noted, dressing changed and patient tolerated the procedure well.
Why A is wrong: Subjective phrases such as looks much better and healing well lack measurable detail; documentation must record objective wound characteristics so that another clinician can compare findings over time.
Why B is wrong: Words such as small and shallow are not measurable, the drainage descriptor yellow fluid does not map to a recognised exudate category, and the peri-wound finding is not quantified, so the entry cannot be reliably trended.
Why C is correct: This entry records the location, dimensions in centimetres, depth, percentage characterisation of the wound bed, drainage type and amount, and the condition of the peri-wound skin, which are the standard objective elements of a wound assessment.
Why D is wrong: Dimensions without units are ambiguous, bloody drainage is not the precise descriptor sanguineous, and the entry omits wound bed appearance, depth, and the condition of the peri-wound skin.