Comprehensive wound evaluation, measurement, photography, and healing progress tracking with evidence-based documentation.
Thorough wound assessment is the foundation of effective treatment. Proper assessment identifies wound etiology (cause), documents baseline status, guides treatment selection, tracks healing progress, satisfies Medicare documentation requirements, and provides legal protection for providers. Without systematic assessment, treatment is guesswork and progress cannot be objectively measured.
Length, width, and depth measured in centimeters at longest and widest points. Undermining and tunneling measured with sterile cotton-tip applicator, documented using clock method (12 o'clock toward head). Wound area calculated (length × width) to track size changes. Measurements taken at every visit for comparison.
High-resolution photos with measurement ruler, proper lighting, and consistent angle. Images capture wound appearance, surrounding skin, and anatomical landmarks. Photos taken at initial visit and every 1-2 weeks to document progress. Essential for Medicare compliance and legal documentation.
Wound bed tissue type documented using percentages: granulation tissue (healthy red), slough (yellow), eschar (black), epithelial tissue (pink). Exudate amount (none, minimal, moderate, heavy) and type (serous, serosanguineous, purulent) recorded. Odor presence noted.
Pedal pulses palpated (dorsalis pedis, posterior tibial). Capillary refill time checked (normal <3 seconds). Ankle-brachial index (ABI) measured if arterial disease suspected. Edema graded 0-4+. Temperature and color of extremity documented. Critical for identifying circulation problems preventing healing.
Protective sensation tested using 10g monofilament (Semmes-Weinstein test). Loss of sensation indicates neuropathy, dramatically increasing ulcer risk and necessitating special precautions. Pain level assessed using 0-10 scale. Increased pain may indicate infection.
Wounds should show measurable improvement every 2-4 weeks. Expected healing trajectory: Week 1-2: Reduced drainage, less slough, decreased inflammation. Week 2-4: Granulation tissue formation (beefy red tissue), wound contraction (edges pulling together), decreased wound size by 10-15%. Week 4-8: Continued size reduction, epithelialization (pink skin growing from edges), potential wound closure. If no improvement after 4 weeks, treatment must be changed.
Medicare requires specific documentation for wound care reimbursement: wound location, size (length × width × depth), tissue type percentages, drainage amount and type, periwound condition, treatment provided, patient response, medical necessity statement, and measurable goals. Photos and measurements must be included at initial visit and regular intervals. Healix360 providers ensure all Medicare documentation requirements are met at every visit, protecting against claim denials.