In this regard, the documentation should include the four main assessment components; which are, nutrition, wound etiology, wound appearance and pain (Assessment and Documentation Issues in Wound Care).

In other words a careful written as well as visual record should be kept of all the possible factors and variables relating to the patient's condition and to the progression or otherwise of the healing process.

There are two further reasons that are important to note with regard to the issue of documentation. These are, firstly, that thorough documentation serves as a legal record of the quality of care and wound management; and secondly, it also provides invaluable information relating to the environment and surroundings that impact the healing process. As one study notes, "….we have seen that the environment of the patient may cause profound difficulties in wound healing. Identifying and understanding these co-morbidities will help you bring in important interventions...
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