Wound Care Note (Hospice)

Date/Time: [Date and time of visit]

Setting: [home / SNF/ALF / inpatient]

Encounter Type: [routine / PRN]; [in-person / telehealth]

Clinician: [Clinician name and credentials]

Participants: [Patient and participating caregivers or facility staff]

Reason for Visit: [Brief reason for visit]

Hospice Context

• Wound management goal: [comfort-focused / healing-focused]
• Relevant clinical factors: [Factors directly impacting wound care decisions] (Include only items that meaningfully affect care.)
• Patient preferences: [Preferences affecting wound care] (Only include if explicitly stated.)

Subjective

[Patient or caregiver report of wound-related symptoms since last assessment, including pain at rest and with care, drainage and dressing saturation, odor, bleeding, caregiver ability to manage dressings, and any new concerns] (If patient cannot self-report, identify the informant.)

Objective

General: [Brief appearance and positioning tolerance; vitals if obtained]

Wound [#]: [Identifier and location] (Repeat this block for each wound addressed.)

• Type/Classification: [Wound type and classification]
• Dimensions (cm): [Length] × [Width] × [Depth]
• Undermining/Tunneling: [Present with measurements and clock positions / absent / not assessed—state reason]
• Wound bed: [Tissue types and approximate percentages]
• Exudate: [Amount and type]
• Odor after cleansing: [none / mild / moderate / strong]
• Periwound: [Skin condition]
• Wound-specific pain: [At rest and with care; scale if provided]
• Bleeding: [none / minimal / moderate / brisk] (Note if provoked by care.)
• Signs of infection: [Local and systemic findings, or none observed]

Interventions — Wound [#]:

• Cleansing: [Method and solution]
• Topicals: [Agents applied]
• Dressings: [Primary, secondary, securement approach]
• Patient response: [Tolerance and response during care]

Assessment & Plan

Wound [#]: [Identifier and location] (Repeat for each wound.)

• Status: [improving / stable / worsening] — [Brief comparison to last visit]
• Goal: [heal / maintain / palliate]
• Dressing regimen: [Materials, frequency, and who performs changes]
• Symptom management: [Pain pre-medication, odor control, exudate containment, bleeding precautions as relevant]
• Escalation triggers: [Specific signs or symptoms prompting call to hospice]

Orders/Coordination: [New or changed orders, supplies needed, IDT or facility communication] (Include only actions decided this visit.)

Next Visit: [Planned timing or PRN parameters]

Caregiver Teaching

(Include only when teaching was provided during this visit.)

• Topics taught: [Topics covered]
• Learner: [Caregiver / facility staff]
• Method: [verbal / demonstration / return demonstration]
• Competency outcome: [verbalized understanding / return-demonstrated correctly / needs reinforcement]
• Barriers: [Barriers identified] (Omit if none.)

Clinician Signature: [Name and credentials] — [Date/Time signed]