During wound assessment documentation, which details should you describe?

• A. Time since last dressing change
• B. Diet and exercise
• C. Patient mood
• D. Wound size, shape, and signs of infection

Answer: (D)

When documenting a wound assessment, focus on the wound itself and how it’s changing. The most important details are the wound’s size, shape, and any signs of infection. Measuring size (length and width, and depth if possible) gives a numeric baseline to track healing. Describing the shape helps capture changes in margins, tissue loss, or re-epithelialization. Noting signs of infection—redness, warmth, swelling, increased or purulent drainage, foul odor, or any systemic symptoms—helps identify complications that may require treatment adjustments.

Other items like time since the last dressing change relate to care timing rather than the wound’s current condition, and factors such as diet, exercise, or mood can influence healing but aren’t the core wound assessment details to document.