Wound Care & Dressing Change Procedure Note

Procedure Note: Wound Care and Dressing Change

Date/Time: [Date and time of procedure]

Location: [clinic / bedside / ED / home visit / other]

Clinician: [Name, credentials]

Patient: [Identifiers per facility policy]

Assistants: [Names and roles, if present]

Interpreter: [Language and interpreter ID / not used]

Procedure Summary

[Wound care and dressing change] [with irrigation / with sharp debridement / with mechanical debridement / with enzymatic debridement / with autolytic debridement / without debridement]. Treated wound site(s): [anatomical location(s) with laterality]. [Number of wounds treated if more than one].

Indications and Goals

• Wound etiology/type: [Stated etiology or classification] (If uncertain, state "etiology uncertain; treatment proceeds while workup is pending.")
• Complicating factors: [Relevant factors affecting healing, e.g., diabetes, PAD, venous disease, neuropathy, edema, immunosuppression, malnutrition risk]
• Indication for today's care: [Reason for today's procedure, e.g., exudate management, biofilm concern, devitalized tissue, dressing failure, periwound maceration]
• Treatment goal: [healing / infection prevention / symptom control / palliation]

Consent

[Verbal / Written] consent obtained after discussion of risks (pain, bleeding, infection), benefits, and alternatives; patient agreed to proceed. [Photography consent obtained per policy / Photography not obtained]. (If consent not obtainable, document reason and policy pathway used.)

Safety Verification

• Patient identity confirmed: [yes / no]
• Correct wound site(s) and laterality verified: [yes / no]
• Allergies reviewed (topicals, adhesives, iodine, silver, latex): [No known relevant allergies / Allergies noted]
• Anticoagulation/bleeding risk reviewed: [yes / no / N/A]
• Technique: [clean / sterile]

(For simple dressing reinforcement without wound exposure, this section may be abbreviated or omitted.)

Pre-Procedure Wound Assessment

(Repeat this section for each wound using consistent numbering.)

Wound #1

Identification: [Anatomical location with laterality and landmarks]; [Wound type/etiology and stage/classification if supported by exam]; [Duration or onset date]

Measurements:

• Dimensions: [L] × [W] × [D] cm (Method: [ruler / standardized protocol]) (If not measured, state reason.)
• Undermining: [Clock-face orientation and depth in cm] [or none]
• Tunneling/sinus tracts: [Direction and length in cm] [or none]
• Surface area: [value] cm² (Document when debridement performed.)

Wound Bed and Periwound:

• Tissue composition: [Granulation, slough, eschar, epithelialization with approximate percentages if used in workflow]
• Edges: [rolled / undermined / attached / other]
• Periwound: [maceration / erythema / dermatitis / callus / induration / intact]
• Exudate: [scant / small / moderate / large], [serous / serosanguinous / purulent], [color]
• Odor: [none / mild / moderate / strong] (assessed [before / after] cleansing)

Pain: Rest pain score: [0-10]. Analgesia already taken: [agent, dose, time / none].

Infection and Perfusion Concerns: (Include when clinically relevant.)

• Local infection signs: [spreading erythema / warmth / purulence / friable tissue / rapid deterioration / none] [Action taken if concern present]
• Perfusion status (lower extremity): [Pulses, known PAD, ABI if on file]; Offloading/compression: [current strategy / none]
• Neuropathy/protective sensation (diabetic foot): [intact / diminished / absent / not assessed]

Procedure Details

Preparation: [Patient positioning]. Prior dressing removed: [atraumatic / adherent / traumatic removal]. Surrounding skin cleansed: [yes / no] with [agent]. Field setup: [clean / sterile].

Anesthesia: [No anesthesia used / Topical: agent, concentration, volume, dwell time / Local infiltration: agent, concentration, volume, method] (If not documented, flag for verification.)

Cleansing and Irrigation: Solution: [normal saline / potable water / commercial cleanser]. Method: [pour / syringe irrigation]. Volume: [approximate mL]. Areas cleansed: [wound bed / edges / periwound]. [Note if loose debris or biofilm-like material removed without tissue removal.] (Do not characterize as debridement unless tissue was removed.)

Debridement: [Debridement not performed; reason: healthy granulation / stable dry eschar / bleeding risk / patient intolerance / other]

OR, if performed:

• Type: [sharp / mechanical / enzymatic / autolytic]
• Instruments: [curette / scalpel / scissors / forceps]
• Tissue removed: [devitalized tissue / slough / eschar / biofilm-laden debris]
• Anatomic depth of removal: [epidermis / dermis / subcutaneous / fascia / muscle]
• Pre-debridement size: [L × W × D or area cm²]; Post-debridement size: [L × W × D or area cm²]
• Total area debrided: [cm²]
• Hemostasis: [pressure / silver nitrate / electrocautery]; EBL: [minimal / moderate / mL]
• Patient tolerance: [well / fair / poorly]

(Clearly distinguish tissue debridement from cleansing of exudate/loose debris. If details missing, flag for completion.)

Topical Agents: [Product name] applied to [wound bed / periwound / both]; Rationale: [antimicrobial / moisture donation / odor control / pain control]. (Omit if none used.)

Dressing Applied:

• Primary contact layer: [non-adherent mesh / hydrofiber / alginate / foam / hydrocolloid / gauze]
• Packing (if cavity/undermining): [material], [amount], loosely packed to [location]
• Secondary layer(s): [absorbent pad / ABD / foam / roll gauze]
• Periwound protection: [barrier film / paste / none]
• Securement: [tape type / wrap / stockinette / adhesive retention sheet]
• Adjuncts: [compression type and level / offloading device / none]
• Change frequency: [every X days/hours]; Performed by: [patient / caregiver / home health / clinic]

Specimens: [Swab culture / Tissue culture] from [wound location]. Photos taken and stored [per policy location]. (Omit entirely if no specimens or photos obtained.)

Post-Procedure Status

• Patient condition: [tolerated well / tolerated poorly]
• Post-procedure pain score: [0-10] (If not documented, flag for verification.)
• Complications: [No complications / complications noted] (If not documented, flag for verification.)
• Post-procedure wound appearance: [Brief description if debridement altered wound bed]
• Disposition: [home / returned to room / higher level of care initiated]

Patient Instructions

• Keep dressing clean and dry; if wet or soiled, [interim management instructions]
• Dressing change frequency: [every X days/hours]; hand hygiene and clean technique emphasized; dispose of supplies safely
• Offloading/compression: [wear/use as prescribed with schedule and precautions]
• Activity and bathing: [limitations or allowances]
• Return precautions: fever, spreading redness, increasing pain, purulent or foul drainage, bleeding not stopping with pressure, new numbness or cool extremity, rapidly worsening swelling
• [Patient preference, refusal, or teach-back confirmation if applicable]

Follow-Up Plan

• Follow-up: [Return in X days / Home health visit in X hours plus provider visit in X weeks]
• Return sooner if: [worsening pain, signs of infection, increased drainage, dressing complications]
• Referrals placed: [wound clinic / vascular surgery / podiatry / infectious disease / home health / none]
• Orders placed: [wound supplies / home health orders / imaging / labs]; Caregiver training: [completed / initiated / N/A]
• If follow-up cannot be arranged: [Document barrier and interim plan]

(For high-risk elements—measurements, debridement details, anesthesia use, complications—do not leave blank; insert placeholder noting information not documented. For optional items like topical agents or specimens, omit entirely if not mentioned. When etiology or staging is uncertain, use qualifiers such as "suspected" or "consistent with." Maintain distinction between cleansing and debridement; do not infer debridement unless tissue removal is explicitly documented.)