Wound Care Discharge/Transition Plan

Document Title: Wound Care Discharge/Transition Plan

Author: [Author name and credentials]

Date/Time of Transition: [Date and time]

Transition Type: [Hospital → Home / Hospital → SNF/Rehab / Wound Clinic → Home / Wound Clinic → PCP / Home Health / Facility Transfer]

Receiving Facility/Setting: [Facility or setting name and contact phone/fax if known]

Intended Recipients: [Specific recipients by role and name if known]

(Global documentation guidance: Timestamp all measurements, cultures, procedures, and regimen changes with dates. Use objective descriptors and centimeters for all measurements. Document undermining and tunneling with clock-face positions. If a measurement, stage, or classification cannot be determined, write "not assessed" or "undetermined" with reason—do not estimate. Omit non-applicable sections; for safety-critical items, include explicit negatives such as "No pending wound cultures" or "No offloading device prescribed." Do not reverse-stage healing pressure injuries—use phrasing such as "healing Stage [X]." If photos were taken, note date and storage location; omit the photo line if none taken.)

Wound Transition Summary

Active Wounds: [Total number] — [Wound types present: pressure injury, diabetic foot ulcer, venous leg ulcer, surgical wound, traumatic wound, etc.]

Highest-Risk Wound(s) and Concern: [Wound ID and key clinical concern] (Explicitly call out any wound at risk for deep infection, ischemia, or deterioration.)

Current Wound Care Modality: [1–2 line summary of the current regimen approach]

Follow-Up Timing Summary: [Next steps and timing windows]

Abbreviated Return Precautions: [3–6 high-risk triggers tailored to this case] (Detailed list in Return Precautions section.)

(If multiple wounds exist, include the following table. Add one row per wound.)

Wound ID	Anatomic Location	Etiology/Type	Stage/Grade	Most Recent Dimensions (L×W×D cm) with Date
[W1]	[Location]	[Etiology/Type]	[Stage/Grade or N/A]	[Dimensions] ([Date])
[W2]	[Location]	[Etiology/Type]	[Stage/Grade or N/A]	[Dimensions] ([Date])

Wound History and Clinical Course

[Onset date and precipitating event; key procedures with dates; prior therapies and response; relevant culture results with antibiotic course; pertinent imaging findings including osteomyelitis workup] (Limit to 1–2 short paragraphs. Omit this section entirely for simple cases where receiving site has current documentation and no significant interventions occurred.)

Wound Assessment

(Organize wounds by clinical risk, highest risk first. Assign stable IDs W1, W2, etc., and maintain consistency across encounters. Repeat this section structure for each wound.)

W1 — [Anatomic Location]

Identification: [Wound type/etiology]; [Classification or stage]; [Present-on-admission status if relevant]

Measurements ([Date]): L×W×D: [cm] | Undermining: [clock positions and max depth, or none] | Tunneling: [clock position and depth, or none] (If not measured, state "not measured" with reason.)

Initial Measurements ([Date]): L×W×D: [cm] (Include to demonstrate trajectory.)

Wound Characteristics:

• Tissue types: [granulation %, slough %, eschar %, epithelium %]
• Exposed structures: [none / fat / fascia / tendon / bone]
• Edges: [attached / rolled/epibole / macerated / undermined]
• Exudate: [none / scant / moderate / large]; [serous / serosanguineous / purulent]
• Odor: [none / present]

Periwound Skin: [Maceration, erythema, warmth, induration, dermatitis, edema, fragility, tape sensitivity]

Pain: Baseline [0–10]; During dressing change [0–10]; [Adaptations required if pain limits care]

Complication Screen:

• Local infection signs: [present / absent / uncertain—requires follow-up]
• Spreading cellulitis: [present / absent / uncertain—requires follow-up]
• Systemic infection signs: [present / absent]
• Ischemia concern: [present / absent / uncertain—vascular assessment ordered]
• Osteomyelitis concern: [present / absent / workup in progress]

Photos: [Date(s) and storage location] (Omit line if none taken.)

W2 — [Anatomic Location]

Identification: [Wound type/etiology]; [Classification or stage]; [Present-on-admission status if relevant]

Measurements ([Date]): L×W×D: [cm] | Undermining: [details or none] | Tunneling: [details or none]

Initial Measurements ([Date]): L×W×D: [cm]

Wound Characteristics:

• Tissue types: [percentages]
• Exposed structures: [none or specify]
• Edges: [description]
• Exudate: [amount and type]
• Odor: [none / present]

Periwound Skin: [Findings]

Pain: Baseline [0–10]; During dressing change [0–10]; [Adaptations]

Complication Screen:

• Local infection signs: [present / absent / uncertain]
• Spreading cellulitis: [present / absent / uncertain]
• Systemic infection signs: [present / absent]
• Ischemia concern: [present / absent / uncertain]
• Osteomyelitis concern: [present / absent / workup in progress]

Photos: [Date(s) and storage location] (Omit line if none taken.)

Current Wound Care Regimen

(Provide stepwise instructions for each wound. If the regimen differs by setting, specify both. Repeat for additional wounds.)

W1 — [Anatomic Location]

1. Cleansing: [Solution and method]
2. Periwound Protection: [Barrier product and application] (Omit if none.)
3. Primary Dressing: [Product type, size, packing instructions and depth limits if applicable]
4. Secondary Dressing: [Cover dressing or wrap]
5. Securement: [Method; alternatives for adhesive sensitivity]
6. Change Frequency: [Schedule] and PRN if [threshold, e.g., saturated beyond 75%]
7. Special Techniques: [Dead space management, offloading integration, other] (Omit if none.)
8. Performer: [RN / trained caregiver / patient]; [Competency status if known]

W2 — [Anatomic Location]

1. Cleansing: [Solution and method]
2. Periwound Protection: [Barrier product] (Omit if none.)
3. Primary Dressing: [Product type, size, packing]
4. Secondary Dressing: [Cover dressing]
5. Securement: [Method]
6. Change Frequency: [Schedule and PRN threshold]
7. Special Techniques: [Details] (Omit if none.)
8. Performer: [Responsible party and competency]

Adjunctive Therapies

(Include only applicable subsections; omit those not relevant to this patient.)

Offloading/Pressure Redistribution

[Device type; wearing schedule; weight-bearing restrictions; repositioning schedule; support surface needs]

Compression Therapy

[Type: multilayer wrap / stocking class / IPC]; [Wear schedule]; [Who applies]; ABI: [result]; [Compression limits based on arterial status if any]

NPWT

[Device and interface]; Settings: [continuous / intermittent], [pressure in mmHg]; Change frequency: [interval]; [Canister management]; [Leak troubleshooting]; Contraindications: [list]; Escalation for device failure: [plan]

Planned Debridement

[Method]; [Frequency]; [Who will perform]

Nutrition

[Protein/calorie goals or supplements]; [Glycemic targets if relevant]

Wound-Relevant Medications

(List only medications directly relevant to wound care. For complete medication list, see discharge medication reconciliation.)

• Antibiotic/antifungal: [Name]; Indication: [reason]; Started: [date]; Stop date: [date]; Monitoring: [labs and schedule]
• Analgesia: [Agent(s)]; Timing: [relative to dressing changes]
• Topicals: [Product and frequency] (Omit if none.)
• Anticoagulation considerations: [Bleeding risk notes relevant to wound care] (Omit if not applicable.)
• Allergies affecting dressing selection: [Adhesive allergy / iodine sensitivity / latex / other]

Supplies and Equipment

(List supplies required to execute the wound care plan.)

Item	Size/Spec	Quantity	Frequency of Use	Substitutes OK?	Procurement	Status
[Primary dressing]	[Size]	[Quantity]	[Per change / daily]	[Yes / No]	[SNF / home health / patient / DME]	[Ordered / delivered]
[Secondary dressing]	[Size]	[Quantity]	[Frequency]	[Yes / No]	[Responsible party]	[Status]
[Additional supplies as needed: skin barrier, NPWT supplies, offloading device, compression garment, support surface]	[Specifications]	[Quantity]	[Frequency]	[Yes / No]	[Responsible party]	[Status]

Patient and Caregiver Instructions

(Include for home transitions; may omit for facility-to-facility transfers. Use plain language.)

• Dressing care: Keep dressing clean and dry; [Bathing guidance and shower protection method]
• Activity: [Weight-bearing and mobility restrictions]; [Offloading/compression use]; Check skin daily for new breakdown
• Pain management: Take [medication] [timing] before dressing changes
• Supplies: [How to obtain supplies]; Call [contact] if supplies run out
• Avoid: [No soaking / no peroxide unless ordered / avoid pressure or shear on wound / other restrictions]
• Teach-back completed: [Yes / No]; Skills demonstrated: [specific skills]; If not achieved: Barrier: [reason]; Plan: [mitigation]

Follow-Up Plan

• Scheduled appointments: [Provider/clinic], [Date/time/location] (Or: to be scheduled within [timeframe] by [responsible party])
• Specialty follow-ups: [Vascular / podiatry / plastics / ID / endocrine], [Timing]
• Home health: Start of care: [Date]; Wound visit frequency: [interval]
• Repeat testing: [Vascular studies / antibiotic monitoring labs / imaging], Target date: [date]
• Task responsibilities: [NPWT changes / suture-staple removal / culture review / supply reorders]: [Assigned to]

Pending Results

(If none, state: "No pending wound-related studies at time of transition.")

Study	Collection Date	Expected Action	Reviewer	Communication Plan
[Wound culture / pathology / imaging]	[Date]	[Action based on result]	[Name/role]	[How patient/receiving facility will be notified]

Return Precautions

Contact wound clinic/PCP/home health same day for:

• Dressing saturation beyond expected threshold
• New or worsening drainage, odor, or pain
• New or worsening redness, warmth, swelling, or streaking
• New wound breakdown near the primary wound
• Device issues (NPWT alarms/leaks, offloading device causing skin injury)

Go to ED or seek urgent evaluation immediately for:

• Fever, chills, or systemic illness with wound changes
• Rapidly spreading redness, severe pain out of proportion, crepitus, blistering, or tissue necrosis
• Uncontrolled bleeding
• New ischemic signs in limb wounds (cold, pale, or blue extremity; rest pain; loss of pulses)
• Acute confusion or low blood pressure with suspected infection

Contact Numbers:

• Wound clinic: [Phone]; After-hours: [Phone]
• Home health agency: [Phone]
• SNF nurse station: [Phone] (if applicable)
• Surgeon/consultant office: [Phone] (if applicable)

Signature

[Authenticated signature with credentials, date, and time]