How to Document a Bedsore for a Potential Legal Claim

Discovering your loved one is suffering from a bedsore is one thing. Understanding what actually happened, and whether the nursing home’s care played a role, is another.

This guide focuses on the practical steps families can take to document a bedsore: what to collect, how to organize it, and how that information can help provide clarity if questions arise later.

When to Start Collecting Evidence

The moment a bedsore is noticed or mentioned is often the best opportunity to begin documenting what is happening. That might occur during a visit, a phone call, or a routine update from the facility, and even injuries described as “minor” can benefit from being recorded early.

Even if some time has passed, it is still worth documenting what you can. It’s common for families to start documenting after new concerns arise or questions remain unanswered for a long period of time. But even when documentation starts later, the details gathered can still help clarify how the situation unfolded.

Photographing the Bedsore

Photographs are often the clearest way to capture how a bedsore looks and how it changes over time. They don’t need to be clinical or professional to be useful, but they should be taken thoughtfully.

Here’s some advice:

• Take photos from more than one angle so the full area is visible.
• Include the surrounding skin to show redness, discoloration, or swelling.
• If possible, include a familiar reference point (such as a ruler or coin) to show size.

Avoid editing or filtering photos, and keep the originals with date and time information intact. This can help establish a timeline later in the claims process.

Requesting and Saving Medical Records

Medical records help explain what was documented about a bedsore and how the facility responded once it was identified. Families generally have the right to request copies of these records.

Rather than trying to collect “everything,” it can help to think in categories:

Daily care records

• Care plans and risk assessments
• Repositioning or turning schedules

Skin and wound documentation

• Skin checks and nursing notes
• Wound care and treatment records

Changes or escalation

• Progress notes
• Records showing changes in condition or treatment

All of this documentation gives you a personal reference to the situation. The opposing party can’t change details – because you can reference the truth, using documentation to back it up.

Documenting Communication With the Nursing Home

Much of what families learn about a bedsore comes through conversations rather than charts. Phone calls, brief updates during a visit, or messages from staff can all contain important details that help establish your case.

It can be helpful to write down:

• When the bedsore was first mentioned
• Who shared the information and their role
• How the injury was explained
• Whether the explanation changed over time

What matters most is writing things down while the details are still clear. Add dates to any notes, too, just so you can reference them later on.

Keeping a Simple Timeline

The timeline of your loved one’s condition and the nursing home’s response, or lack thereof, forms the backbone of your claim. It helps connect the dots between what families were told and what was happening behind the scenes, while exposing negligent behavior in between.

For example, a timeline can show when the first skin issue was noticed, when the family was notified, and what changed afterward. Laying events out in order can make it easier to see where delays or missed steps may have occurred.

When a nursing home refuses to communicate or cooperate, creating a timeline becomes challenging, or even impossible. Legal action can force them to play fair, but remember, you’ll need an experienced attorney to go the distance.

How to File a Bedsore Claim, Step by Step

With all your information in hand, it’s time to file a claim. Here’s an overview of what to expect:

Step 1: Contact a nursing home attorney for an initial review

Families can start by contacting a law firm that handles nursing home bedsore cases, like Morgan & Morgan. During this conversation, your attorney will ask basic questions about the resident, the facility, when the bedsore was discovered, and how it was explained. 

Step 2: Share the information you have

Photos, medical records, and notes from conversations can be shared with the attorney for review. You don’t need to have complete or perfectly organized records at this stage, as attorneys are accustomed to working with partial information and identifying what may be missing.

Step 3: Allow the attorney to request records and investigate

If your family decides to move forward, your attorney can formally request records from the nursing home, review care plans and staffing information, and consult with medical professionals as needed. This begins your team’s investigation, while the nursing home may begin theirs.

Step 4: Decide how to proceed

Once your attorney has reviewed the information, families can decide whether to pursue a claim. In some cases, that may involve filing a lawsuit. In others, it might not be in your best interest to move forward. The decision is entirely yours, and it’s based on the unique circumstances of your case.

Once families reach this point, the next step is deciding whether they want to keep managing the paperwork and communication themselves or have a legal team handle those details on their behalf.

Morgan & Morgan, America’s Largest Personal Injury Firm, works with families at this stage to review what happened, explain what the documentation shows, and handle communication with the nursing home when appropriate. With 1,000+ nationwide and offices across the country, our team has the resources to take on complex nursing home cases and keep your best interests protected, from start to finish.

Get started today with a free, no-risk case evaluation.

Frequently Asked Questions

How do you document a bedsore in a nursing home?

Documenting a bedsore usually involves a combination of photos, medical records, and notes about when the injury was discovered and how it was explained. Even simple documentation can help preserve details that may become harder to recall over time.

What evidence is needed for a nursing home bedsore claim?

Evidence often includes photographs, care records, and notes about communication with the nursing home. Our team can help determine which details are most relevant based on how and when the injury developed.

Should I take photos of a bedsore?

Yes. Photos can help show how a bedsore looks and how it changes over time, which is information that written descriptions alone may miss. They do not need to be professionally taken to be useful.

Can I request medical records from a nursing home?

In most cases, families have the right to request copies of their loved one’s medical records. Keeping your own copies can be helpful if questions arise later or if explanations change.

Is it too late to document a bedsore if I waited?

Often, no. Many families begin documenting after a wound worsens or new concerns come up, and that is common. Information gathered later can still help clarify what happened.

Do I need a lawyer to start documenting a bedsore?

No, any family can document a bedsore on their own. A lawyer can become helpful later if you want assistance reviewing the information or understanding possible next steps.