A wound care note records one wound at one visit: what it is, how big it is, what the bed and the skin around it look like, what you did, and the plan. Copy the free template, see a sacral pressure injury and a diabetic foot ulcer example, and check how to measure, stage, and describe a wound.
Blank wound care note template
FreeWOUND CARE NOTE Patient: [Name, date of birth] Date and time: [Date, time] Setting: [Clinic, home visit, long-term care, or hospital unit] Visit type: [Initial assessment, weekly reassessment, dressing change, or discharge from wound care] Clinician: [Name, credentials] Others present: [Family, caregiver, interpreter, or none] WOUND HISTORY Wound type: [Pressure injury, diabetic foot ulcer, venous leg ulcer, arterial ulcer, surgical wound, skin tear, or trauma] Cause: [What caused it and what keeps it open, such as pressure, shear, footwear, swelling, or poor blood flow] Location: [Body site and side, with landmarks] Duration: [Date first noticed or acquired, and where] Classification: [NPIAP stage for a pressure injury; Wagner, University of Texas, SINBAD, or WIfI for a diabetic foot ulcer; partial or full thickness for other wounds] Treatment so far: [Dressings, offloading, compression, antibiotics, and how it has gone] Healing factors: [Diabetes and last A1c, vascular disease, smoking, steroids, nutrition, mobility, continence] Pressure injury risk: [Braden score and date, or not applicable] MEASUREMENTS Measured: [Position, and before or after cleansing and debridement] Size: [Length head to toe × width side to side × depth, in cm] Area: [Length × width in cm², and the change since the last measurement] Undermining: [Depth in cm and clock positions, with 12 o’clock toward the head, or none] Tunneling: [Depth in cm and clock position, or none] Healing score: [PUSH tool or BWAT score, and the last score, or not used] WOUND BED AND SURROUNDINGS Tissue: [Percent granulation, slough, eschar, and epithelium; any exposed bone, tendon, or fascia] Exudate: [Amount: none, small, moderate, or large; type: serous, serosanguineous, sanguineous, or purulent] Odor: [None, or present after cleansing] Edges: [Attached, rolled, callused, or epithelializing] Periwound skin: [Intact, red, macerated, dry, callused, swollen, or indurated, and how far it extends in cm] Infection signs: [Warmth, spreading redness, swelling, pus, new pain, odor, fever; probe to bone and X-ray results if done] Pain: [Score and scale, at rest and during care, and what was given] Circulation: [Pulses, capillary refill, ABI or toe pressures and date, for a lower-limb wound] Sensation: [10 g monofilament result, for a foot wound] Photo: [Taken with consent, a ruler, and a label, and where it is stored, or not taken] CARE GIVEN Cleansing: [Solution and method] Debridement: [None, autolytic, enzymatic, mechanical, conservative sharp, or surgical: what was removed, and any bleeding] Dressing: [Primary dressing, secondary dressing, and how often to change it] Periwound protection: [Barrier film, barrier cream, or none] Offloading or compression: [Device or compression system, and the ABI it is based on] Tolerance: [Pain and how the patient managed during care] PLAN Goal: [Healing, maintenance, or comfort, as agreed with the patient] Dressing changes: [Frequency, and who does them] Pressure relief: [Repositioning schedule, support surface, seating, heel offloading] Nutrition and glucose: [Intake, weight, supplements, dietitian, glucose targets] Referrals: [Podiatry, vascular, dietitian, infectious disease, plastic surgery, or none] Teaching: [What the patient or caregiver was taught, and what they understood] Escalation: [Signs that need a call or an earlier visit] Next measurement: [Date] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Long-term care home, weekly wound round, wound care nurse
Evelyn Marsh, born April 2, 1944, 82 years old. November 9, 2026, at 10:15, room 214. Weekly reassessment. Clinician: Nina Castellano, RN, wound care nurse. Present: Tom Reyes, care aide, helping with positioning.
Pressure injury over the sacrum, midline. Acquired during a 6-day hospital stay for pneumonia. First documented on her return to the home on October 19 as unstageable, with yellow slough covering the base. Restaged as stage 3 on October 26, once autolytic debridement showed the base: full-thickness skin loss with fat visible, and no fascia, muscle, tendon, or bone. Cause: pressure and shear from long periods on her back in hospital. Healing factors: moderate Alzheimer’s dementia, needs 2 people to reposition, urinary incontinence, and 3 kg (7 lb) lost in the 2 months before the hospital stay. No diabetes. Braden 13 today, moderate risk.
Lying on her left side, after cleansing. Today: 3.4 × 2.5 × 0.5 cm; area 8.5 cm². Undermining 0.3 cm at 12 o’clock. No tunneling. November 2: 3.8 × 2.8 × 0.6 cm; area 10.6 cm²; undermining 0.6 cm from 12 to 2 o’clock. October 26: 4.2 × 3.1 × 0.8 cm; area 13.0 cm²; undermining 1.0 cm from 11 to 2 o’clock. Area down 35% in 2 weeks. PUSH tool 12, down from 14 on October 26.
Tissue: 80% red granulation, 20% yellow slough at the upper edge; on October 26, 60% granulation and 40% slough. No eschar. Exudate: small, serosanguineous; was moderate and serous. No odor after cleansing. Edges attached, with new pink epithelium along the lower edge; no rolled edges. Periwound skin intact, with no redness or maceration. No warmth, spreading redness, swelling, pus, or new pain. T 36.8 °C (98.2 °F). Pain: PAINAD 2 during cleansing, grimacing as the slough was cleaned; 0 at rest. Scheduled acetaminophen given 30 minutes before care. Photo taken with a measuring guide and label; consent on file from her daughter, her health care decision-maker.
Cleansed with normal saline at low pressure. Autolytic debridement continues under the dressing; no sharp debridement needed. Calcium alginate placed lightly into the base and the undermining at 12 o’clock. Silicone bordered sacral foam over it, to be changed every 2 days and whenever soiled or lifting. Barrier cream to the buttocks, kept clear of the dressing border. Tolerated care calmly after the pre-medication.
Goal: healing; on track at about a third smaller in 2 weeks, so the plan continues. Reposition every 2 hours in bed with a 30-degree side tilt, off the sacrum, on the air mattress. Head of bed 30 degrees or lower except at meals. Sitting limited to 1 hour at a time on a pressure-redistributing cushion. Heels floated. Nutrition: weight 54.0 kg (119 lb), up 0.4 kg in 2 weeks; eats about 75% of meals with help. Dietitian target 1.25 to 1.5 g of protein per kg a day, 68 to 81 g; high-protein supplement twice a day. Continence care every 2 hours and as needed, with a pH-balanced cleanser. Call the nurse practitioner for new odor, spreading redness, more exudate, fever, or a larger wound. Daughter updated by phone. Next measurement November 16. Signed: Nina Castellano, RN, November 9, 2026, 10:50.
Hospital outpatient wound clinic, new referral, wound clinic physician
Victor Huang, born May 14, 1965, 61 years old. November 9, 2026, at 13:30. New patient, referred by his family physician. Clinician: Dr. Amara Okafor, MD. Present: his wife.
Diabetic foot ulcer, right plantar foot, under the first metatarsal head. Started about 5 weeks ago as a blister under a callus, after he began wearing new steel-toe work boots. He didn’t feel it; his wife noticed blood on his sock. Treated at home with gauze and antibiotic ointment; no oral antibiotics. Type 2 diabetes for 14 years; A1c 9.2% on October 30. No known peripheral artery disease, no earlier ulcers or amputations, never smoked. Warehouse supervisor, on his feet most of his shift. Classification: Wagner grade 1. SINBAD 2 of 6, for loss of protective sensation and an area over 1 cm².
Lying on his back, after cleansing and sharp debridement. 1.4 × 1.1 × 0.3 cm; area 1.5 cm². Length runs heel to toe, width across the foot. Before debridement, the callus rim made the opening look 0.8 × 0.6 cm. No undermining or tunneling. Probe to bone negative, with a sterile blunt metal probe.
Tissue after debridement: 100% red granulation; before, 30% slough under a thick callus rim. Exudate: small, serous. No odor after cleansing. Edges callused, a 4 mm rim, pared away. Periwound: no redness, warmth, swelling, or maceration. Uninfected by IWGDF/IDSA criteria; T 36.9 °C (98.4 °F). Plain X-ray of the right foot: no bone erosion, gas, or foreign body. Pain: 0 of 10; he can’t feel the area. Circulation: dorsalis pedis and posterior tibial pulses palpable; Doppler waveforms biphasic; ABI 0.95 right, 1.00 left. Sensation: 10 g monofilament not felt at the 3 sites tested on each foot; vibration absent at both great toes with a 128 Hz tuning fork. Photo taken with his consent, with a ruler and label.
Cleansed with normal saline. Conservative sharp debridement with a No. 15 blade: callus rim and slough removed down to bleeding tissue; pinpoint bleeding stopped with pressure. Thin foam dressing over the ulcer. Knee-high total contact cast applied, padded over the bony prominences, after the X-ray and ABI. Tolerated it with no pain.
Goal: healing, then preventing a recurrence. Total contact cast: first change on November 12 as swelling goes down, then weekly, with the ulcer measured and the dressing changed at each change. Cast care taught to him and his wife: keep it dry, wear the cast shoe, walk as little as possible, and call the same day for rubbing, swelling, a bad smell, or fever. Note given for seated duties at work while in the cast. Glucose: letter to his family physician about the A1c of 9.2%, asking for a review of his diabetes medicines; diabetes educator referral. Vascular: toe pressures and toe-brachial index ordered, since the ABI can read falsely normal in diabetes; vascular surgery review if they show peripheral artery disease, or if the ulcer hasn’t shrunk by about half in 4 weeks. Podiatry: shared care for casting and callus, then custom insoles and footwear once healed, including a check of any new work boots. Next measurement November 12. Signed: Dr. Amara Okafor, MD, November 9, 2026, 14:40.
What the wound is, how it started, and what is stopping it from healing. The type decides how you classify it: NPIAP stages fit pressure injuries only.
Avoid: Leaving out the cause. “Sacral wound” says nothing; “pressure and shear from lying on her back” points to the fix.
The numbers that show whether a wound is healing. Measure at least weekly, in the same position, after cleansing, with length head to toe and width side to side at right angles to it.
Avoid: Switching methods between visits. If one clinician measures head to toe and the next measures the longest line, the trend means nothing.
What the base of the wound is made of, and what is coming out of it. Tissue percentages often show progress before the size changes.
Avoid: Judging odor with the old dressing just off. Many dressings smell on removal; cleanse first, then decide.
The edges show whether new skin is growing in. The skin around the wound shows moisture damage, pressure, callus, or spreading infection.
Avoid: Reading no pain as no problem. In a foot without protective sensation, a deep infection can be painless.
What you did at this visit, in enough detail for the next clinician to repeat it.
Avoid: “Dressing changed.” Name each layer, so the next clinician doesn’t have to guess.
What happens until the next measurement, and who does it. Tie each step to the cause of the wound.
Avoid: A dressing plan with nothing for the cause. Without offloading, compression, or enough blood flow, no dressing will close the wound.
NPIAP stages are for pressure injuries only. Describe venous, arterial, and surgical wounds as partial or full thickness, and grade a diabetic foot ulcer with a system made for it, such as SINBAD or Wagner.
A stage 3 that is filling in doesn’t become a stage 2: the tissue that grows back is scar, not the layers that were lost. Write “healing stage 3” until it closes.
Record an ABI before compressing a leg ulcer. Many guidelines use full compression only at an ABI of 0.8 or higher, and ask for specialist advice below that. In diabetes the ABI can read falsely high, so add toe pressures.
If a wound hasn’t shrunk by about 40 to 50% in 4 weeks, look again at the cause, blood flow, infection, offloading, and nutrition before trying another dressing.
A photo without a ruler, a date, and a site label can’t be compared with the next one. Get consent, and take it from the same angle and distance each time.
Vero Scribe writes the wound care note in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Start with the wound type, its cause, its location, and how long it has been there. Measure length, width, and depth in cm after cleansing, then undermining and tunneling by clock position. Describe the wound bed in percentages, the exudate, odor after cleansing, the edges, the skin around it, and any signs of infection. Then record what you did, the dressing, any offloading or compression, and the plan, with the next measurement date.
Position the patient the same way each time and cleanse the wound first. Measure length from head to toe, and width from side to side at right angles to it, in cm. For depth, place a sterile cotton-tipped swab at the deepest point, mark it at skin level, and hold it against a ruler. Measure undermining and tunneling the same way, and note the clock position, with 12 o’clock toward the head.
Undermining is tissue loss under intact skin around part of the wound edge, like a shelf, so the wound is wider under the surface than at it. Tunneling is a narrow channel that runs from the wound into deeper tissue in one direction. Record both with a depth in cm and a clock position, such as undermining 1.0 cm from 11 to 2 o’clock, or a tunnel 2.5 cm at 6 o’clock.
No. Pressure injuries aren’t reverse staged. As a stage 3 or 4 fills in, the new tissue is scar, not the fat, muscle, and skin that were lost, so it stays a healing stage 3 until it closes. An unstageable injury gets its stage once the slough or eschar is removed and the base can be seen.
Yes. Copy it, or download it as a Word or text file. No account needed.
Wound assessments, measurements, and care plans, drafted from the visit for your review.
Notes for diabetic foot visits, from callus care to offloading and footwear.
Consent for the wound photos you take at each visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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