Wound Care Follow-Up/Progress Note

Date: [Date of service]

Patient: [Patient name and identifier]

Provider: [Provider name and credentials]

Wound ID / Location / Etiology: [Stable wound identifier] — [Anatomical location with laterality] — [Wound type: pressure injury / venous leg ulcer / diabetic foot ulcer / surgical / traumatic / other]

Days Since Last Visit: [Number of days]

Reason for Visit

[Single-sentence reason for follow-up] (State interval reassessment purpose; note if post-procedure follow-up or escalation visit.)

Interval History

[Adherence and symptom changes narrative] (Cover: treatment adherence as reported by patient/caregiver; pain trend with 0–10 rating; changes in drainage, odor, or bleeding; systemic symptoms; intervening care; relevant medication changes especially anticoagulants, immunosuppressants, or recent antibiotics. State explicitly if medication reconciliation was not performed.)

Wound Assessment

Vitals: [Vital signs] (Include if concern for infection or per clinic protocol; otherwise state "Vitals not obtained" or omit.)

Regional Exam: [Focused exam of affected limb/region] (Include edema, erythema, tenderness, vascular status, and neurologic status as relevant to wound etiology.)

Wound Measurements: [Length] × [Width] × [Depth] cm by [measurement method]; Prior: [prior size]; Change: [percent change] (Include undermining/tunneling with clock-face location and depth if present. If no prior measurement, state "No prior measurement for comparison.")

Wound Bed: [% granulation] / [% slough-fibrin] / [% eschar-necrosis] (Note if debridement indicated.)

Exudate: [none / light / moderate / heavy] — [serous / serosanguinous / purulent] — [odor description]

Periwound: [Edge characteristics: attached / rolled / macerated] — [Surrounding skin findings]

Infection Assessment: [Infection assessment statement] (Document local signs assessed: increased pain, erythema, warmth, swelling, purulence, malodor, friable tissue. Use "no signs of infection observed today" rather than "no infection." Note culture type and indication if obtained.)

Assessment

[Clinical interpretation] (State trajectory as [improving / stable / worsening] with objective basis. Identify barriers to healing. Do not restate observations from above.)

Plan

Wound Care Orders: [Cleansing, debridement plan if indicated, topical agents, primary and secondary dressings with change frequencies] (Write orders with explicit frequencies.)

Compression/Offloading: [Device, level, and wear schedule] (Include only if applicable to wound etiology.)

Infection Management: [Diagnostics, antibiotics, or drainage plan with duration] (Include only if clinically indicated.)

Referrals: [Vascular, diabetes, nutrition, PT, orthotics, home health as indicated] (Omit if none planned.)

Escalation Criteria: [Return precautions for patient: fever, spreading erythema, increased pain/drainage/odor, new necrosis]

Follow-Up: [Interval] — [Setting] — [Return sooner for specified concerns]

Procedure Note

(Include this section only if debridement or other wound procedure performed today. Omit entirely if no procedure.)

Procedure: [Name] — [selective / excisional] — [method/tool]

Indication: [Clinical rationale]

Consent/Anesthesia: [Consent obtained from patient/guardian] — [Anesthesia type and amount, or "None"]

Pre-Procedure Measurements: [L × W × D cm; undermining/tunneling if present]

Tissue Removed: [Type(s), depth, area in cm²]

Hemostasis: [Method]

Tolerance/Complications: [Patient tolerance] — [Complications or "None"]

Post-Procedure: [Wound bed appearance] — [L × W × D cm] — [Dressing applied]

Post-Procedure Instructions: [Care instructions, activity limits, return precautions]

(If an element cannot be assessed, state "Unable to assess [element] because [reason]." Do not infer absence of infection or ischemia—document explicit assessment or state "not assessed." Each visit requires fresh documentation; do not copy forward without attestation.)