Paired entries for this system. The left column is denial-bait; the right column is the same clinical picture written so a reviewer can see why a nurse was required.
Weak — does not survive
Why it fails
Strong — defensible
“Wound healing well.”
No measurement, no comparison, no skilled reason — a layperson observation.
“Stage 3 sacral PI 2.4×1.8×0.3 cm, down from 3.0×2.2 cm; 90% granulation; offloading effective; plan continued.”
“Dressing changed.”
Records a task, not skilled assessment or trajectory.
“Sterile dressing change per order; bed 80% granulation, scant serous exudate, periwound intact; healing on trajectory.”
“Wound looks worse.”
Subjective, no objective change or action.
“Wound increased to 3.2×2.4 cm with new 0.6 cm undermining at 12 o’clock and purulent exudate; MD notified, culture ordered.”
“Redness around wound.”
No measurement of spread, no risk, no action.
“1.5 cm periwound erythema with warmth, new from baseline; concerning for local infection; MD notified, antimicrobial started.”
“Patient educated on wound care.”
No content, no learner response.
“Repositioning and dressing protection taught; caregiver return-demonstrated correct technique; gaps in offloading schedule addressed.”
“Tolerated dressing change.”
Not quantified, no skilled judgment.
“Pre-medicated per order; pain 6→2/10 with care; no bleeding; tolerated packing of 2 cm tunnel; reassess pain next visit.”
