Negative Pressure Wound Therapy (NPWT) Dressing Change Procedure Note

Date/Time: [Procedure date and time]

Setting: [home / outpatient wound clinic / SNF / inpatient]

Procedure: Negative Pressure Wound Therapy (NPWT) Dressing Change

NPWT Start Date: [Start date]

Ordered Frequency: [Ordered frequency]

Indication & Wound List

[Primary indication for NPWT] (Do not infer staging or etiology; if relying on prior notes, state "per prior documentation.")

• Wound [identifier]: [Location and laterality]; [Wound type/classification if established]; [Rationale to continue NPWT in 1–2 sentences]

(Repeat for each wound being treated.)

Interval History

[Patient-reported course since last dressing change: pain level, odor, fever/chills, functional impact. Device course: alarms, seal issues, therapy interruptions, canister changes. Any bleeding or infection concerns.] (If no interval concerns, state "No interval concerns reported.")

Pre-Procedure

• Orders verified: [Target pressure in mmHg], [mode: continuous / intermittent / variable], [dressing change frequency]
• Pain management: [pre-medication given / topical anesthetic applied / none] (Include agent, dose, route, timing if administered.)
• Technique: [clean / sterile]
• Risk/contraindication screen: [Anticoagulation status, exposed critical structures, untreated infection, other relevant risks] (Omit if not applicable.)

Wound Assessment

(Repeat this subsection for each wound treated.)

Wound: [Identifier / location / laterality]

Measurements: [Length] × [width] × [depth] cm; undermining [present at depth and clock-face location / absent]; tunneling [present at depth and clock-face location / absent] (If measurement cannot be obtained, document reason and plan to re-measure.)

Wound Bed: [Tissue types: granulation / slough / eschar / epithelialization with approximate proportions]; exposed structures [none / tendon / bone / fascia / vessel]

Drainage: [none / scant / small / moderate / large] amount; [serous / serosanguinous / sanguinous / purulent] character; [none / mild / strong] odor

Periwound: [normal / maceration / erythema / dermatitis / edema]

Infection Signs: Local signs [present / absent]; systemic signs [present / absent]

Progress: [Comparative statement vs prior assessment with date and values] (e.g., "Surface area decreased 15% from [date]" or "Depth improved by 0.5 cm from [date].")

NPWT System Status (Pre-Removal)

• Observed settings: [Target pressure in mmHg]; [mode: continuous / intermittent / variable]
• Seal integrity: [intact / leak at location]
• Canister: [Fill level or volume in mL]; [drainage appearance]; [changed: yes / no]
• Dressing configuration: [Foam type: black / white / combination]; contact layer [present / absent]; bridging [yes with route / no]

Procedure Details

Dressing Removal: Therapy paused. Drape and tubing removed. [Materials removed with count] (e.g., "Removed 2 black foam pieces intact, 1 non-adherent contact layer."). [All materials removed intact / fragmentation concern: describe assessment and actions]. (Required: explicitly document material count removed.)

Wound Care: [Irrigation solution and technique]. Debridement [not performed / performed: type, tissue removed, hemostasis method]. (If debridement documented separately, reference that note.)

Periwound Protection: [Barrier film / hydrocolloid / paste / protective contact layer applied] (Include if indicated.)

New Dressing Application: [Materials placed with count] (e.g., "Placed 2 black foam pieces, 1 contact layer; drape applied."). [Management of undermining/tunnels if applicable]. (Required: explicitly document material count placed.)

Seal & Restart: Leak test performed; [seal achieved / persistent leak addressed with intervention]. Therapy resumed at [pressure] mmHg [mode]. [Setting changes from prior with rationale, if any].

Post-Procedure

• Tolerance: Pain [score 0–10]; [tolerated well / tolerated with difficulty]
• Dressing Status: Seal [intact / not intact]; target pressure [achieved / not achieved]; alarms [absent / present]
• Complications: [None / bleeding / periwound injury / retained material concern / device malfunction] (Use explicit negative documentation: "No complications.")
• Specimens: Cultures [none obtained / obtained from site by method]

Medical Necessity & Plan

• Healing Progress: [Measurable change over prior month: surface area, depth] (If limited progress, document barriers to healing.)
• Continued Need: [Link ongoing NPWT to current wound characteristics: persistent depth, undermining, exudate burden, granulation needs, graft/flap protection]
• Plan: [Continue / adjust / discontinue] NPWT at [pressure] mmHg [mode]; [dressing change frequency]; [next follow-up]. Concurrent measures: [offloading, compression, nutrition optimization, pressure redistribution, debridement plan as applicable]
• Escalation Criteria: [Triggers to notify provider: bleeding, fever, purulence, worsening pain, persistent seal failure]