Whirlpool Hydrotherapy Treatment Note (Wound/Burn)

Date of Service: [Date] (If unavailable, enter "Not documented: [reason]")

Clinician: [Clinician name and credentials]

Care Setting: [Inpatient acute / Outpatient clinic / SNF / Home health / Burn unit / Other]

Visit Type: Whirlpool Hydrotherapy Treatment Note (Wound/Burn)

(This template documents a single whirlpool hydrotherapy session for wound/burn care. For any clinical item not assessed, document "Not assessed: [reason]" rather than omitting. Do not infer normal findings. For billing-critical fields—date, time, intervention identification, and signature—use "Not documented: [reason]" if unavailable. Do not diagnose infection or assign staging unless directly assessed and within scope.)

Indication & Order Context

[Indication for whirlpool today, wound type/etiology, treated body region(s) with laterality, order/referral context] (State the purpose of hydrotherapy such as wound cleansing, loosening adherent dressings, or facilitating planned debridement. Include only history directly relevant to hydrotherapy risk.)

Safety Screening

• Baseline pain level: [0–10 / qualitative description]
• Sensation (treated area): [Intact / Diminished / Absent / Not assessed: reason]
• Hemodynamic tolerance: [Tolerates upright/immersion / Orthostasis risk / Cardiac precaution / Not assessed: reason]
• Cognition/ability to follow commands: [Adequate / Limited / Requires cues / Not assessed: reason]
• Wound-related precautions: [Active infection / Isolation status / Fragile tissue / Bleeding risk / None / Not assessed: reason]
• Thermal risk factors: [Impaired sensation / Vascular compromise / Neuropathy / None / Not assessed: reason]
• Pre-medication for procedural pain: [Medication, dose, route, time given / None]

Pre-Treatment Wound Status

(Repeat the following wound block for each wound/burn treated in this session.)

[Wound identifier]: [Location and laterality]

• Visualization: [Fully visualized / Partially visualized / Not visualized: reason and indirect observations]
• Measurements: [Length × Width; Depth if applicable]
• Tissue characteristics: [Necrotic tissue, slough/eschar, granulation, epithelialization]
• Exudate: [Amount, type, odor if present]
• Periwound: [Erythema, edema, maceration, other findings]
• Pain at wound: [0–10 / qualitative]
• Staging/classification: [Stage/classification] (Only if directly assessed and within scope; otherwise "Not assessed: reason" or omit.)

Whirlpool Parameters & Infection Control

• Tank type: [Full body / Extremity / Hubbard / Other]
• Water temperature (measured): [Value and units]
• Agitation/turbulence: [Setting and directionality if applicable]
• Additives: [Name and concentration / No additives]
• Infection control: [Equipment disinfection status, liner use, PPE, isolation precautions followed]
• Water treatment parameters: [Chlorine residual, pH] (Include only if measured per facility protocol.)

Treatment Delivery

• Duration: [Total minutes] (Or start/stop times if required: Start [time], Stop [time].)
• Clinician attendance: [Direct one-to-one throughout / Intermittent observation per policy]
• Patient position: [Seated / Supine / Limb supported / Other]
• Interventions during immersion: [Cleansing, debris removal, dressing removal assistance, ROM, other]
• Interruptions/events: [None / Description of event, action taken, and duration impact]

Patient Response & Tolerance

• Pain ratings: Pre [0–10], During [0–10], Post [0–10] (Or qualitative report.)
• Observed tolerance: [Guarding / Grimacing / Withdrawal / Autonomic symptoms / Fatigue / No overt distress]
• Skin response: [Excessive erythema / Maceration / Bleeding / Increased edema / Contact reaction / None observed]
• Vital signs: [Values and changes / No significant change / Not monitored] (Include if patient is medically fragile or heat exposure is a concern.)
• Patient statements: [Direct quotes clarifying symptoms or concerns] (Include only if patient provides meaningful statements.)

Post-Treatment Wound Status

(Mirror pre-treatment structure; describe immediate observable changes only. Repeat for each wound/burn treated.)

[Wound identifier]: [Location and laterality]

• Tissue changes: [Slough loosened, wound bed visibility, granulation status, other immediate changes]
• Exudate changes: [Amount/type/odor compared to pre-treatment]
• Periwound: [Condition post-treatment including maceration/erythema/edema changes]
• Bleeding/trauma: [None / Minimal / Description and management provided]
• Concerns requiring escalation: [Increasing erythema, purulence, malodor, other / None]

Follow-Up Care & Plan

• Post-whirlpool care: [Rinse/irrigation solution and method, skin protection measures]
• Dressing applied: [Products and layers] (If applied by another discipline, document handoff.)
• Positioning/elevation instructions: [Instructions for edema prevention / Not applicable]
• Next session: [Planned date/interval, parameter changes, criteria for stopping or altering treatment]
• Patient education: [Topics covered]
• Clinical interpretation: [Brief linkage from observed response to plan] (Accept concise interpretation such as "improved wound bed visualization after loosening slough.")

Time & Billing

• Total treatment time: [Minutes] (Enter actual minutes; do not substitute units. If unavailable, "Not documented: [reason]")
• Intervention identification: Whirlpool hydrotherapy
• Additional timed procedures today: [Procedure(s) and minutes each / None]

Signature: [Clinician signature with credentials]

[Contributing assistant/student names and roles] (Include per facility policy if applicable.)