Wound Care Procedure Note (Assessment, Dressing Change, or NPWT)

Date/Time: [Encounter date and time]

Setting: [clinic / bedside / home health / skilled nursing / other]

Note Type: Wound Care Procedure Note

Subtype: [Assessment only / Dressing change / NPWT application or change][ + Debridement] (Append "+ Debridement" only if debridement occurred today.)

Author/Role: [Author name, credentials, and role]

(Use stable wound IDs consistently across visits for longitudinal tracking. Omit sections not applicable to today's encounter subtype. For assessment-only encounters, omit "Procedure Performed" and "Post-Procedure Status." Include "Pre-Procedure Safety" only for NPWT or debridement. Use "Not assessed today" when an item was not evaluated, "Unknown" when information is unavailable, and "Denied" only for symptoms explicitly asked about.)

Reason for Visit

[Primary indication for today's encounter in 1–3 sentences, including wound etiology if known (pressure injury, venous leg ulcer, diabetic foot ulcer, surgical dehiscence, traumatic wound, burn, other) and anatomic location with laterality] (If etiology unclear, state "etiology unclear" and list leading possibilities.)

Interval History

[Patient-reported changes since last visit: drainage, pain, odor, bleeding, device alarms for NPWT, dressing adherence issues, trauma, new symptoms] (State "No interval change reported" if appropriate; omit section entirely if no relevant updates.)

[Comorbidities affecting healing: diabetes control, PAD, venous disease, immunosuppression, malnutrition, smoking, edema] (Include only if relevant to today's assessment.)

[Current supportive therapies: offloading, compression, repositioning/turning schedule, support surface, nutrition plan, edema management] (Include only if relevant to today's assessment.)

[Bleeding risk factors: anticoagulants, antiplatelets, thrombocytopenia, friable vessels; allergies to wound products] (Include only for NPWT or debridement encounters.)

Pre-Procedure Safety

(Include this section only for NPWT initiation/change or debridement. Omit for assessment-only and routine dressing change encounters unless required by institutional policy.)

• [Time-out verification: correct patient, procedure, site/side, wound(s) to be addressed; or reference to separate time-out documentation]
• [Consent: obtained per policy / verbal consent documented / documented elsewhere at (location)]
• [Contraindication screen for NPWT: necrotic tissue/eschar requiring debridement first, suspected untreated osteomyelitis, malignancy in wound, unexplored fistula, exposed vessels/organs/anastomosis, bleeding risk] (Document "no contraindications identified" or specify concerns and mitigation.)
• [Analgesia plan: agent/dose/route/timing administered / patient declined / not indicated]
• [Technique: clean / aseptic / sterile]

Wound Assessment

Wound Inventory: [List each wound by stable identifier and location, e.g., "Wound 01 – Right lateral malleolus," "Wound 02 – Left plantar forefoot"] (Maintain the same IDs across visits.)

Wound [ID]: [Anatomic location with laterality] – [Etiology/Type] – [Stage/Classification if applicable]

Measurements: [Length] × [Width] × [Depth] cm; [measurement method: greatest perpendicular dimensions / clock method; depth by probe / visual estimate]; [Undermining: depth in cm at clock-face positions]; [Tunneling/sinus tracts: depth in cm at clock-face positions] (If unable to measure, state reason and proxy assessment used. If wound healed/closed, document closure status and date if known.)

Wound Bed: [Approximate percentages of tissue types: granulation, slough/fibrin, eschar/necrosis, epithelial]; [Exposed structures: tendon / bone / hardware / fascia / vessel]; [Foreign material: sutures / staples / debris] (Note if visualization is limited.)

Edges and Periwound: [Edges: attached / non-attached / rolled / epibole / callus / macerated]; [Periwound: erythema (measure margin in cm if present), warmth, edema, induration, maceration, dermatitis, adhesive injury]

Exudate: [Amount: none / scant / small / moderate / large]; [Type: serous / serosanguinous / sanguineous / purulent]; [Odor: none / mild / moderate / strong, persists after cleansing: yes / no]; [Bleeding: none / oozing / moderate / significant]

Pain: [Score at rest: 0–10]; [Score during care: 0–10]; [Analgesia used and effect]; [Pain out of proportion to findings or change from baseline: yes / no]

Infection Screen: [Local signs: erythema, warmth, swelling/induration, tenderness, purulent discharge]; [Systemic signs if present: fever, tachycardia, altered mental status]; [Clinical impression: low / moderate / high concern for infection with rationale]; [Probe-to-bone if performed: positive / negative / not performed; diagnostic plan if osteomyelitis suspected] (Avoid stating "no infection" without documented supporting findings.)

Photo: [obtained and stored per policy / not obtained]

(Repeat the above wound block for each wound addressed today.)

Procedure Performed

(Include this section only when intervention occurred beyond observation. Omit entirely for assessment-only encounters. Include only subsections applicable to today's procedure.)

Dressing Change

• [Old dressing removed: type/components, adherence, saturation level]
• [Cleansing: solution and method]
• [Periwound protection: barrier film / paste / none]
• [Primary dressing: contact layer, antimicrobial if used, absorptive layer, packing material with quantity/length]
• [Secondary dressing: type]
• [Securement: tape / wrap / retention device]
• [Adjuncts: compression type and pressure class, offloading device, other]
• [Change frequency and responsible party: patient / caregiver / home health / clinic]

Negative Pressure Wound Therapy (NPWT)

(Include only when NPWT was initiated, changed, or adjusted today.)

• [Indication: initiation / continuation / dressing change]; [Clinical goal]
• [Device/system]; [Interface: foam / gauze]; [Contact layer: type / none]; [Bridge configuration if used]
• [Settings: target pressure (mmHg); mode: continuous / intermittent / variable; instillation parameters if applicable]
• Dressing/Foam Count: [Number removed]; [Number inserted]; [Counts match: yes / no] (If discrepancy, document resolution.)
• [Seal: achieved / not achieved; troubleshooting performed if needed]
• [Canister: changed / emptied / retained; output amount and character]
• [Patient tolerance and pain control]
• [Complications: none / bleeding / device malfunction / leakage; actions taken]
• [Next scheduled change: date and responsible party]

(If NPWT present but not changed today: [Device status: running, settings verified, seal intact; reason not changed])

Debridement

(Include only when debridement was performed.)

• [Type: selective sharp / non-selective sharp / mechanical / autolytic / enzymatic]; [Tissue level removed]
• [Instruments used]
• [Surface area debrided (cm²) and wound ID(s) addressed]
• [Hemostasis: method and bleeding amount]
• [Anesthesia/analgesia: agent, route, dose / none required]; [Patient tolerance]

Post-Procedure Status

(Include only when a procedure was performed.)

• [Wound appearance after care: cleaner bed, reduced odor, bleeding controlled, NPWT seal achieved, dressing intact]
• [Pain level after procedure and overall tolerance]
• [Adverse events: none / describe event and mitigation]
• [Disposition: returned to baseline activity / specific precautions / monitoring instructions]

Assessment

(Provide clinical synthesis for each wound. Organize by wound ID with highest-risk wounds first. Anchor status statements with objective findings.)

Wound [ID]

• [Status: improving / stable / worsening]; [Objective basis: measurement trend, tissue change, exudate change, other]
• [Infection concern: low / moderate / high]; [Rationale]
• [Current regimen: continue / adjust with rationale]

(Repeat for each wound addressed.)

Plan

• Local wound care: [Dressing regimen with components and layering; frequency; acceptable substitutions; who performs changes]
• NPWT orders: [Device; interface; pressure (mmHg); mode; instillation if applicable; change frequency; troubleshooting guidance; criteria to pause or discontinue] (Include only if NPWT ordered.)
• Adjunctive therapy: [Offloading device and wear schedule; compression type/class; repositioning/turning schedule; support surface; edema management; smoking cessation; nutrition/supplementation]
• Diagnostics and consults: [Cultures with collection method; labs; imaging; vascular evaluation; specialty consults]
• Follow-up: [Next visit date or timeframe; criteria for earlier return]

Escalation Parameters

• Fever or systemic illness
• Rapidly expanding erythema or increased warmth/swelling
• New purulent drainage or sudden increase in exudate
• Malodor persisting after cleansing
• New or worsening severe pain, or pain out of proportion to exam
• Significant bleeding, especially with NPWT
• NPWT device failure not correctable or repeated alarms with clinical deterioration
• Signs of limb ischemia

Education Provided

(Include only if education was given during encounter.)

• [Topics covered: dressing care, hand hygiene, offloading/compression adherence, NPWT alarms and canister management, activity restrictions, warning signs]
• [Understanding confirmed via teach-back: yes / no]
• [Written instructions provided: yes / no]

(If education deferred: [Reason and plan for completion])