Wounds Pressure Injury

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Trace DC28-6

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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4. Normal findings

“Normal/at-baseline” for an existing wound means it is on or holding its expected healing trajectory under the current order. Each line states the finding, the baseline comparison, and the skilled reason a nurse was required — a bare “wound healing well” does not qualify.

  • Wound dimensions stable or decreasing versus the prior visit, measured and compared to confirm a healing trajectory.
  • Wound bed predominantly granulation (beefy-red), with slough and eschar stable or decreasing.
  • Exudate scant to moderate and consistent with the phase of healing, without odor.
  • Periwound intact or improving, without new erythema, maceration, induration, or warmth.
  • Pain stable or decreasing and controlled with the current regimen and dressing schedule.
  • Dressing and offloading or compression in place, correct per order, and effective.
  • No local or systemic signs of infection; the plan is appropriate to continue unchanged.
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