SOP: Skin Tear and Wound Reporting
Standard for skin tear assessment, documentation, and reporting.
SOP: Skin Tear and Wound Reporting
Procedure for assessing, documenting, and reporting skin tears and wounds.
Assessment
- Classify skin tear type (I–III)
- Measure L x W x D; photo with consent
- Pain score and infection signs
Documentation
- Wound note in EHR with measurements
- eMAR treatment added and scheduled
- Notify provider and Responsible Party
Download: Wound Assessment Form (PDF)