Negative-Pressure Wound Therapy (NPWT) Initiation Note

Date/Time: [Encounter date and time]

Location: [clinic / inpatient / home visit / skilled nursing facility / other]

Clinician: [Clinician name and credentials]

Note Type: NPWT Initiation Note

NPWT Start Date: [Date therapy first applied] (If initiated at another facility, note the facility name and best available original start date. If uncertain, document the best estimate and plan to verify.)

Clinical Indication & Eligibility

[Primary wound problem and why NPWT is indicated now] (Describe current wound challenges such as heavy exudate, depth/undermining, failure of prior therapy, need to promote granulation, or dehiscence.)

• Therapeutic goals: [exudate control / granulation formation / wound contraction / protection of wound environment / bridging to definitive closure] (Select all that apply.)
• Qualifying wound category: [Chronic ulcer (include duration) / Surgical wound complication / Traumatic wound complication]
• Wound(s) selected for NPWT: [Wound IDs and locations receiving NPWT] (If multiple wounds exist, briefly state why any others are excluded.)

Relevant Healing History

(Include only factors that influence NPWT planning, risk, or follow-up intensity. Omit items not relevant to this patient.)

• Glycemic status: [Diabetes status and most recent A1c, or not applicable]
• Vascular/venous disease: [Peripheral arterial disease / venous insufficiency / none / unknown] (Include relevant testing if known.)
• Neuropathy: [present / absent / unknown]
• Nutritional risk: [Assessment summary and any interventions]
• Immunosuppression: [Medications or conditions, or none]
• Tobacco use: [Status and counseling if applicable]
• Anticoagulant/antiplatelet use: [List agents / none / unknown] (If unknown and relevant to bleeding risk, state plan to clarify.)
• Mobility/offloading limitations: [Description or none]
• Continence/moisture issues: [present / absent] (Include management approach if present.)

Prior Comprehensive Wound Therapy

(Required for chronic ulcer pathways; optional for acute surgical/traumatic complications. Document only measures actually addressed. If performed elsewhere and records are unavailable, document patient-reported history and plan to obtain records.)

• General measures:
  • [Regular wound evaluation and measurements by licensed professional; approximate duration]
  • [Moist wound dressings used: types and frequency]
  • [Debridement of necrotic tissue: dates/types performed, or reason deferred]
  • [Nutritional assessment findings and any interventions]
• Etiology-specific measures: (Include only those applicable to wound etiology.)
  • Pressure injury: [Turning/repositioning schedule; support surface; moisture/incontinence management]
  • Diabetic/neuropathic ulcer: [Glycemic optimization; pressure reduction/offloading method]
  • Venous ulcer: [Compression therapy details; leg elevation adherence]
  • Arterial insufficiency: [Vascular evaluation results/plan; risk mitigation steps]

Contraindication Screen

(Answer each with Yes/No/Uncertain and add comments when positive or uncertain. If proceeding despite risk, document rationale and mitigation plan.)

• Necrotic tissue with eschar present: [yes / no / uncertain] [Comments; if present, document debridement performed or plan]
• Osteomyelitis not being treated with curative intent: [yes / no / uncertain] [Supporting basis for determination]
• Malignancy in the wound: [yes / no / uncertain] [Comments]
• Fistula to organ or body cavity: [yes / no / uncertain] [Comments]
• Exposed vessels, organs, nerves, or anastomotic sites: [yes / no / uncertain] [Comments]
• High bleeding risk: [yes / no / uncertain] [Risk factors and mitigation plan if present]

(If any risk is present but proceeding with NPWT, document protective strategies such as interface layer selection, reduced pressure settings, or increased monitoring frequency.)

Baseline Wound Assessment

(Repeat the following block for each wound receiving NPWT.)

Wound [ID]: [Anatomical location with laterality]

• Etiology/classification: [Pressure injury with stage / Diabetic foot ulcer / Venous / Arterial / Surgical dehiscence / Traumatic / Mixed]
• Date first noted: [Date or best estimate] (Source: [patient report / medical record / other])

Measurements: [Length] × [Width] × [Depth] cm; Surface area: [calculated value or not calculated]

• Undermining/tunneling: [Clock-face positions with depth in cm] (If unable to measure depth safely, state reason and specify alternative tracking metric.)
• Wound bed composition: [Percent granulation / slough / eschar]; [Exposed structures if any]
• Wound edges: [attached / unattached / rolled / macerated / other]
• Periwound skin: [intact / macerated / erythematous / indurated / fragile / other]

Drainage:

• Amount: [none / scant / moderate / heavy]; [Quantify when possible: estimated mL/day, canister volume over interval, or dressing saturation frequency]
• Type: [serous / serosanguinous / sanguineous / purulent]
• Odor: [none / mild / strong]
• Infection indicators: [Localized warmth / erythema / increased pain / purulence / systemic symptoms / none]

Pain: Baseline [0-10]; with dressing changes [0-10]; Analgesia plan: [Planned approach]

Photos: [obtained with consent / not obtained] (If obtained, note storage location.)

NPWT Application

(Include only if NPWT was applied during this encounter. If ordered but not applied today, document "NPWT not applied today; will be initiated by [home health / at next encounter / other]" and proceed to NPWT Prescription.)

• Wound cleansing: [Method and solution]
• Debridement performed today: [Type / none]; [Anesthesia used]; [Hemostasis method]
• Interface/contact layer: [Type and rationale]
• Filler: [foam / gauze / specialty foam]; Piece count: [Number placed] (Document for reconciliation at removal.)
• Bridging: [used / not used] [Details if used]
• Drape and seal: [Placement description]; Seal confirmed: [yes / no]; Leak test: [method and result]
• Canister: [Size and type]; Initial output: [mL or none]
• Patient tolerance: [well tolerated / complications encountered] [Actions taken if applicable]

NPWT Prescription

• Device type: [durable pump / disposable single-use system] [Brand/model if relevant]
• Negative pressure setting: [mmHg]; Mode: [continuous / intermittent] (If intermittent: [on duration] / [off duration])
• Dressing components: [Filler material]; [Interface layers]; [Periwound barrier products]
• Dressing change frequency: [every 48 hours / every 72 hours / other]
• Canister: [Size and type]; anticipated change frequency: [interval]
• For home NPWT:
  • Dressing changes performed by: [patient / caregiver / home health / clinic visits]
  • Escalation contacts: [Contact names and numbers for problems]
  • DME supplier: [Name or pending]

Patient/Caregiver Education

• Topics reviewed: Purpose and expected benefits of NPWT; device operation (on/off, battery/charging, maintaining seal); alarm troubleshooting and who to call; activity guidance and bathing restrictions; signs of infection to report; dressing change expectations
• Bleeding emergency plan reviewed: Recognize bleeding → stop NPWT → apply direct pressure → call emergency services if significant
• Education provided to: [patient / caregiver / both]
• Method: [verbal / written materials / demonstration]
• Teach-back confirmed understanding: [yes / no] (If no, document plan to reinforce.)
• Barriers and mitigation: [Vision / dexterity / cognition / language barriers identified and mitigation plan, or none identified]

Follow-up Plan

• Dressing change schedule: [Frequency and responsible party]
• Measurement schedule: At dressing changes when feasible; formal documented comparison at least monthly for coverage
• Next reassessment appointment: [Date/time or interval]
• Discontinuation criteria: Therapy will be discontinued if no measurable wound improvement over [interval], if adequate healing allows transition to another modality, or if safety concerns arise (bleeding, intolerance, inability to maintain seal/adherence).
• Coverage documentation: Wound progress documentation will be provided to supplier/payer as required.

Signature

[Clinician signature, credentials, date]

(If foam or gauze filler was placed, confirm piece count documented for reconciliation at removal.)