Abnormal findings are charted as a chain — finding, severity, comparison to baseline, the risk it creates, and the skilled action taken — never as a bare observation.
Increase in wound dimensions, new undermining, or new tunneling versus baseline — deterioration requiring reassessment of etiology, offloading, and the treatment order.
New or increasing slough or eschar, or a wound bed converting from granulation to non-viable tissue — stalled or declining healing.
New or increasing purulent or malodorous exudate, periwound erythema, warmth, or induration — concerning for local wound infection.
Spreading erythema beyond the periwound, streaking, fever, or new confusion — concerning for cellulitis or systemic infection.
Exposed bone or a positive probe-to-bone in a non-healing wound over a bony prominence — concerning for osteomyelitis.
New deep-tissue injury (maroon/purple intact skin or a blood-filled blister) or an injury that cannot be staged because of slough/eschar — unstageable or DTI requiring a revised plan.
New or uncontrolled pain disproportionate to the wound, or pain with crepitus and dusky tissue — possible necrotizing infection.
Bleeding from the wound, especially in a patient on an anticoagulant — requiring control and bleeding-risk review.
