Inpatient Wound Care Consultation Note

Date/Time of Note: [Date and time of documentation]

Consult Date/Time: [Consult date/time] (Include only if different from Date/Time of Note)

Consulting Service/Author Role: [Consulting service and author role/title]

Requesting Clinician/Service: [Requesting clinician and service]

Primary Reason for Consult: [One-line statement of the specific wound concern]

Relevant Precautions: [Contact isolation / anticoagulation / bleeding risk / weight-bearing restrictions / immunosuppression] (Include only if applicable; omit entire line if none)

Reason for Consult

[Restated consult question in 1–3 lines] (If the original request was unclear, document what was clarified and with whom.)

Brief Impression

• [Number of wounds assessed and overall acuity]
• [Most critical diagnosis/concern]
• [High-priority wound: type + location + stage/classification + key complication] (Add additional bullets for other high-priority wounds as needed.)
• [Immediate actions recommended or orders placed today]

History

[Wound-focused HPI: onset and timeline, present on admission vs developed inpatient, suspected etiology, symptoms, prior and current wound care, barriers to care] (Use direct patient quotes when documenting refusal or intolerance affecting care.)

[Inpatient risk factors: mobility/positioning status, perfusion concerns, moisture exposure, nutrition/metabolic factors, devices creating pressure risk, sensation/neuropathy status, immunologic factors] (Required for pressure injuries, DFU, ischemic, or infected wounds. If patient cannot participate in history, document "unable to obtain patient-reported history; chart review performed.")

[Targeted PMH/Medications/Allergies relevant to wound care: diabetes, PAD, venous disease, neuropathy, ESRD, CHF, malnutrition, smoking, autoimmune disease, anticoagulants/antiplatelets, immunosuppressants, topical allergies]

Objective

Vitals/Clinical Status: [Temperature trend, hemodynamics, oxygen requirement, level of consciousness and cooperation]

Pertinent Labs: [CBC, BMP, glucose/A1c, CRP/ESR] (Include when relevant to wound type. Document "not available at time of consult" if pertinent labs not obtained.)

Imaging/Vascular Studies/Microbiology: [Relevant imaging, ABI/toe pressures, culture results with specimen source] (Document "not available" if relevant studies pending.)

Physical Exam

• General: [Appearance, distress, ability to reposition, tolerance of turning]
• Vascular: [Pedal pulses, capillary refill, temperature, dependent rubor, edema] (Include for lower extremity wounds)
• Neurologic: [Protective sensation status] (Include for diabetic foot wounds when feasible to assess)
• Foot Structure: [Deformity, Charcot suspicion, weight-bearing status] (Include for diabetic foot wounds)

Wound Assessment

Wound Inventory:

• W1 — Type: [Type]; Location: [Anatomic site + laterality]; Stage/Classification: [Stage or classification]; Dimensions: [L × W × D cm]; POA: [Y / N / Unknown]; Photo: [Y / N]
• W2 — [Repeat as needed for each wound]

W[#]: [Location + Laterality] — [Wound Type]

(Repeat this subsection for each wound using consistent W# IDs.)

• Stage/Classification: [Pressure injury stage 1–4 / unstageable / DTPI; DFU infection severity grade and depth/structure involvement; venous/arterial/postoperative/MASD classification] (Include device-related or mucosal labels when applicable.)
• Measurements: [Length × width × depth in cm with method noted; undermining depth and clock-face orientation; tunneling depth and clock-face orientation] (If measurement unsafe, document reason deferred.)
• Wound Bed and Edges: [Percent granulation/slough/eschar, exposed structures, edge characteristics]
• Exudate: [Amount: none / scant / small / moderate / large]; [Character: serous / serosanguinous / purulent]; [Odor: present / absent]
• Periwound Skin: [Erythema extent, warmth, induration, maceration, dermatitis, callus]
• Pain: [Baseline pain level; pain with palpation/dressing change]
• Infection Assessment: [Local signs, systemic signs if present] (For DFU: include infection severity grade and osteomyelitis concern with supporting evidence.)
• Perfusion Assessment: [Pulses, cap refill, temperature gradient, ABI/toe pressures, ischemic features] (Include for lower extremity wounds.)

(Staging guidance: Stage only what is visible today; use "unstageable" when wound bed obscured by slough/eschar. Do not reverse stage—describe healing wounds as "healing stage [X] pressure injury with granulation and decreasing depth." Differentiate pressure injury from MASD/IAD based on location over bony prominence and non-blanching erythema vs diffuse moisture-related distribution.)

Assessment

• [Priority 1]: [Diagnosis (type + location)], [Stage/classification], [Complicating factors], POA: [Y / N / Unknown], Contributors: [pressure / shear / moisture / neuropathy / PAD / device]
• [Priority 2]: [Repeat as needed]

(If etiology uncertain, document differential and what would clarify.)

Plan

Global Prevention Orders

(Include when pressure injury risk or multiple wounds present.)

• Repositioning: [Frequency and acceptable positions; head-of-bed angle limits; exceptions]
• Offloading: [Heels floated, heel protector devices, chair pressure redistribution, sitting time limits]
• Support Surface: [Mattress type and chair cushion]
• Moisture Management: [Incontinence skin care protocol, barrier products, wicking underpads, fecal containment]
• Skin Surveillance: [Frequency, responsible team, device-related skin checks]

Wound-Specific Orders

(Create sub-list for each wound using W# IDs. Use imperative wording.)

• W[#]:
  • Cleansing: [Method and product]
  • Periwound protection: [Barrier film/cream]
  • Primary dressing: [Product, size, packing instructions]
  • Secondary dressing/securement: [Type; specify silicone-based if MARSI risk]
  • Change frequency: [Interval and strike-through criteria]
  • Offloading/activity: [Wound-specific offloading orders]
  • Pain management: [Premedication and timing for dressing changes]

Escalation Triggers

• Increased erythema beyond marked borders
• New purulence or odor
• Fever or hypotension
• Increasing necrosis or eschar instability
• Uncontrolled bleeding
• Worsening ischemic changes (coolness, cyanosis)

DFU-Specific

(Include only for diabetic foot ulcers.)

• Infection severity grade and disposition: [Outpatient vs inpatient pathway]
• Offloading strategy: [Preferred device and contraindications if not using first-line]
• Culture guidance: [Deep tissue preferred after cleansing/debridement]
• Osteomyelitis workup: [Probe-to-bone, imaging, labs, biopsy plan]

Postoperative Wound

(Include only for postoperative wounds.)

• Wound status: [Superficial vs deep dehiscence, fascia integrity]
• Urgent surgical notification criteria: [Evisceration concern, rapidly spreading erythema, crepitus, systemic toxicity]

Debridement

(Include if debridement performed or planned.)

• Method and rationale: [Conservative sharp / autolytic / enzymatic / mechanical / surgical] (Note contraindications: ischemia, stable dry heel eschar, anticoagulation.)
• If performed today: [Consent, analgesia, technique, findings, estimated blood loss, complications, post-procedure dressing]

Consults and Interdisciplinary Care

(Include referrals placed or recommended.)

• Dietitian: [Indication]
• PT/OT: [Mobility/positioning/offloading needs]
• Vascular surgery: [Ischemia concern]
• Podiatry/Orthopedics: [Foot wound/offloading/surgical needs]
• Infectious Diseases: [Complex infection]

Follow-up

• Reassessment timing: [Interval]
• Ownership: [Wound team vs primary team vs nursing tasks]
• Discharge planning: [Home health, supplies, outpatient wound clinic, offloading equipment]

Communication

Notifications: [Who notified (RN, primary team, surgery, podiatry), method, and timing]

Orders: [Orders entered vs recommendations only] (Clearly distinguish what was ordered vs suggested.)

Patient/Family Education: [Topics covered and understanding demonstrated]

(Use "Not assessed," "Not available," or "Unable to assess" with brief reason rather than leaving blanks. Attribute data from chart review or nursing report with source notation. Include trend comparisons only when prior measurements can be cited.)