Wound Assessment Documentation at the Time of Discharge
- The discharging clinician must complete and document a wound assessment before the patient leaves the facility. The wound assessment must record: the wound closure method (sutures, staples, tissue adhesive, steri-strips, or a subcuticular closure); the condition of the wound edges at discharge (well-approximated, intact, without separation or dehiscence); the presence and character of any drainage (serous, serosanguineous, or sanguineous; scant, moderate, or copious); the condition of the periwound skin (intact, without signs of erythema, warmth, or induration extending beyond the wound margin); and the type of dressing applied before discharge. A discharge note that states only 'wound clean and dry' without these specific assessment parameters does not constitute an adequate wound assessment under AORN or WOCN documentation standards and may be insufficient to defend against a later claim that a wound complication was not identified before discharge.
- Wound size and depth documentation at discharge is required when the wound is expected to heal by secondary intention (open wounds, dehisced wounds, or wounds intentionally left open for delayed primary closure). For these wound types, the discharge documentation must record wound dimensions in centimeters (length, width, and depth at minimum), wound base tissue type (granulation tissue, slough, eschar, or exposed bone or tendon), and undermining or tunneling status if present. The Wound, Ostomy and Continence Nurses Society (WOCN) recommends wound measurement using a consistent method, with the length measured along the craniocaudal axis, width along the mediolateral axis, and depth using a sterile probe or applicator. Serial measurements at follow-up visits require documentation of the same parameters to allow comparison for healing trajectory assessment.
- Discharge documentation must record whether wound drainage devices (Jackson-Pratt drain, Blake drain, Hemovac, or other closed suction device) are present at discharge and must include patient education about drain management. Drain management instructions must specify: how to empty the drain bulb and record output; the maximum output level that is within expected range versus output that warrants provider contact; how to assess the drain site for signs of infection or dislodgement; when the provider anticipates removing the drain (typically when output falls below 30 mL in a 24-hour period for most closed suction drains); and what to do if the drain becomes dislodged or the tubing is disconnected. Documentation that a patient was discharged with a surgical drain without recorded drain education creates a liability exposure if the patient later reports that drain management was not explained.
- When a patient is discharged with a wound vac (negative pressure wound therapy, NPWT) device, the discharge documentation must confirm that the patient or caregiver received training on device operation, including: how to assess the dressing seal; how to recognize and respond to device alarms; the expected therapy pressure setting; the frequency of canister changes; and the wound care provider or home health agency responsible for dressing changes. NPWT dressing changes require specialized training and are typically performed by a wound care nurse rather than the patient; the discharge documentation must identify the provider or agency that will perform dressing changes and confirm that the first visit has been scheduled. Patients discharged home with NPWT without a scheduled wound care follow-up appointment are at risk for dressing failure and device-related pressure injury.
Dressing Selection Documentation and Patient Instruction Standards
- Discharge documentation must identify the primary dressing applied to the wound and the rationale for selection. AORN perioperative practice standards recommend that dressing selection be based on wound characteristics: wound moisture level (wet versus dry), drainage quantity and character, wound depth, and the presence of infection. Dressings for clean, closed surgical wounds with minimal drainage are typically simple gauze or transparent film dressings. Dressings for wounds with moderate to heavy drainage require an absorbent secondary dressing to prevent strike-through, which creates a pathway for bacterial contamination. A dressing selected for its absorption properties must be documented as such; discharge instructions that do not explain dressing selection rationale leave the patient unable to make an appropriate substitution if the prescribed dressing is unavailable.
- Patient dressing change instructions must specify: the frequency of dressing changes (daily, twice daily, or per wound characteristics); the supplies required (type of primary dressing, secondary dressing if applicable, wound cleanser if prescribed, gloves); the wound cleaning method before applying a new dressing (sterile saline rinse, wound cleanser, or gentle soap and water depending on wound type and patient setting); and the hand hygiene required before and after dressing changes. The WOCN and AORN both support patient self-care with clean technique rather than sterile technique for most home wound care settings, as studies in community wound care support that clean technique produces equivalent outcomes to sterile technique for non-immunocompromised patients managing wounds at home. This distinction must be explained in the discharge instruction so that patients do not feel they are performing wound care incorrectly when they use clean technique.
- Discharge instructions for surgical wounds healing by primary intention (closed with sutures, staples, or adhesive) must include specific guidance on bathing and incision care. Instructions must address: when the patient may get the incision wet (typically after 48 hours for most primary-closure wounds, consistent with evidence cited in the AORN Guidelines for Perioperative Practice); the cleaning method (patting dry rather than rubbing); restrictions on submerging the incision in a bath or pool (typically until the incision is fully sealed and sutures or staples are removed); and topical products to avoid without provider instruction (hydrogen peroxide and povidone-iodine are cytotoxic to healing tissue and should not be applied to healing primary-closure wounds). Instructions that state 'keep wound dry' without a specific timeline or that do not address showering versus bathing leave patients with insufficient guidance.
- Specialty wound types require specialty-specific documentation at discharge. For breast surgery patients, discharge instructions must address drain care (typically present after mastectomy), activity restrictions that protect the surgical site, and signs of seroma formation. For colorectal or perineal surgery patients with perineal wounds, discharge instructions must address perianal hygiene, sitz bath frequency and technique, dietary recommendations to avoid constipation and straining at the wound site, and the wound care provider responsible for follow-up assessment. For orthopaedic surgery patients, instructions must address incision protection under a cast or splint when applicable, and signs of compartment syndrome (pain out of proportion to the procedure, paresthesia, and pallor of the distal extremity) that require emergency evaluation. These specialty-specific elements cannot be captured in a generic wound care discharge template.
Suture and Staple Removal Timelines and Infection Warning Signs
- Discharge documentation must specify the timeline for suture or staple removal, which varies by anatomical location and wound tension. Standard suture removal timelines by location based on widely cited surgical principles: scalp wounds, 7 to 10 days; facial wounds, 3 to 5 days; neck wounds, 5 to 7 days; anterior trunk wounds, 7 to 10 days; extremity wounds (low tension), 10 to 14 days; extremity wounds over a joint (high tension), 14 days; posterior trunk and gluteal wounds, 14 days. Subcuticular absorbable sutures do not require removal but may require removal of external steri-strips at 7 to 14 days. Discharge instructions that specify 'sutures to be removed at follow-up' without a target date leave the patient without a reference point for scheduling the follow-up appointment and may result in delayed removal.
- Wound infection warning signs must be listed explicitly in post-operative discharge instructions because early identification of surgical site infection (SSI) enables prompt treatment before the infection extends to deeper tissue planes. The Centers for Disease Control and Prevention (CDC) defines SSI categories (superficial incisional, deep incisional, and organ or space SSI) with timing criteria of within 30 days of the index procedure for most SSI types, and within 90 days for procedures involving implant placement. Patient-facing discharge instructions should describe SSI warning signs in plain language: increasing (rather than decreasing) pain at the incision site 24 to 48 hours after surgery; redness or warmth extending beyond the immediate wound margin and worsening over time; swelling at the wound site that increases rather than resolves; purulent (thick, cloudy, or malodorous) drainage from the wound; and fever above 38.0 degrees Celsius (100.4 degrees Fahrenheit). Instructions must direct patients to contact the provider's office for any of these findings and to seek emergency care if systemic symptoms such as high fever above 39.0 degrees Celsius, rigors, or rapidly spreading redness are present.
- Tissue adhesive (surgical glue, cyanoacrylate) wound closure requires different discharge instructions than suture or staple closure. Patients with tissue adhesive closure must be instructed: not to pick at or peel the adhesive film, which will separate naturally over 5 to 10 days as the epidermis regenerates; not to apply ointments, petroleum jelly, or other topical products over the adhesive, as these may dissolve the adhesive prematurely; not to submerge the adhesive-closed wound in water until the adhesive has separated completely; and to pat rather than rub the area when drying after showering. Tissue adhesive provides tensile strength only during the early proliferative phase of wound healing; activities that place tension on the wound margins must be restricted until the adhesive has separated and wound healing has progressed, typically 7 to 14 days depending on location.
- Documentation of patient-reported allergy or sensitivity to wound care products is required before applying a dressing or prescribing a home wound care regimen. Common wound care contact sensitivities include reactions to adhesive tape or dressing adhesives (adhesive-related contact dermatitis), reactions to iodine-containing antiseptics such as betadine, and reactions to silver-containing products used for infected or high-contamination-risk wounds. If a patient reports a history of adhesive allergy, the discharge dressing must use a non-adhesive retention method (such as gauze wrapped with a self-adherent wrap), and the discharge instructions must specify adhesive-free alternatives for home dressing changes. A wound complication arising from an allergic reaction to a prescribed wound care product when the allergy was documented in the patient's pre-operative assessment represents a documentation and care coordination failure.