WOUND 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]