Wound Culture/Specimen Collection Procedure Note

Date/Time of Collection: [Date and time]

Location/Setting: [bedside / clinic / ED / procedure room / other]

Clinician Performing Collection: [Name and credentials] (Required; do not infer. Flag as incomplete if not explicitly documented.)

Wound Identifier: [Facility wound map/number if applicable]

Indication & Clinical Rationale

[Clinical concern prompting culture, including signs/symptoms of infection, relevant risk factors, reason culture is needed now, antibiotic timing relative to collection, and how results will inform management. If wound does not appear clinically infected, include specific justification for obtaining culture.] (Required; establishes medical necessity. Flag as incomplete if missing.)

Specimen Source

(Required; use precise anatomic and procedural descriptors suitable for the specimen label. Avoid nonspecific labels such as "wound" alone.)

• Anatomic Site: [Laterality and precise location, e.g., "left plantar forefoot, base of ulcer beneath 1st metatarsal head"]
• Wound Type: [diabetic foot ulcer / pressure injury / surgical wound / abscess / venous ulcer / traumatic wound / other]
• Specimen Depth/Compartment: [superficial swab / deep tissue curettage / needle aspiration / punch biopsy / hardware submission]
• Culture Tests Ordered: [aerobic / anaerobic / Gram stain / fungal / AFB / other]
• Exact Source Text for Specimen Label: [Source wording to appear on label]

Pre-Procedure Checks

• Patient Identification: [Verified per facility policy] (Do not infer.)
• Relevant Allergies: [Allergies to prep agents, anesthesia, adhesives, or none identified]
• Bleeding Risk Assessment: [Assessment details / not applicable] (Include if biopsy, curettage, or aspiration.)
• Analgesia/Anesthesia: [Agent, dose, route, response / not used]
• Time-Out: [Completed / not applicable per policy] (Required for invasive procedures; do not infer.)

Wound Preparation

• Gross Assessment: [Wound appearance and surrounding skin findings]
• Cleansing/Irrigation: [Solution and method]
• Debridement: [Method and extent / not performed—reason]
• Specimen Obtained From: [Precise location within wound, e.g., base of debrided ulcer, abscess cavity, advancing margin]
• Contamination Avoidance Measures: [Steps taken to avoid periwound skin, necrotic tissue, surface exudate]

Collection Procedure

(Include only the subsection corresponding to the method used. Do not infer method; flag as incomplete if not explicitly documented.)

Deep Tissue Curettage

• Instrument: [Curette type/size]
• Tissue Source: [Confirmation specimen obtained from viable tissue at wound base]
• Number of Specimens: [Count]
• Hemostasis: [Method / not required]

Needle Aspiration

• Skin Preparation: [Antiseptic agent and technique]
• Site/Depth Aspirated: [Location and depth]
• Aspirate Appearance/Volume: [purulent / serosanguinous / bloody / other; approximate volume]
• Transfer: [Transport container used]

Punch Biopsy

• Biopsy Site & Rationale: [Location and reason for site selection]
• Biopsy Size: [Diameter]
• Local Anesthesia: [Agent, concentration, volume]
• Hemostasis: [Method]
• Closure/Dressing: [Sutures / adhesive / none; dressing type]

Swab Culture

• Justification for Swab: [Reason tissue sampling not feasible, e.g., pain, bleeding risk, wound characteristics] (Required; do not generate swab documentation without explicit justification.)
• Preparation: [Wound bed cleansed, surface exudate removed]
• Technique: [Swab applied with pressure to viable tissue, avoiding wound edges and periwound skin]

Specimen Handling & Transport

• Container/Transport Medium: [Container type; anaerobic transport device if applicable]
• Labeling: [Two patient identifiers, date/time, exact source text, tests requested, collector initials]
• Transport: [Sent immediately / hand-delivered / tube system; temperature considerations if applicable]
• Lab Communication: [Special handling requests, urgent Gram stain, or none]
• Transport Delay: [Reason, interim storage, recollection consideration] (Omit if no delay.)

Post-Procedure Status

• Hemostasis: [Achieved—method / not required]
• Dressing: [Type applied]
• Patient Tolerance: [Tolerated well / discomfort managed / other]
• Complications: [None / complication and response taken]

Management Plan

• Current Antibiotic Status: [None started / empiric therapy initiated—agent and rationale / already on antibiotics—response assessment]
• Anticipated Management Based on Results: [How culture results will guide antibiotic adjustment, need for imaging or surgery, referrals, isolation precautions]
• Follow-Up Plan: [Who will review results, timeframe, patient notification method, contingency if unreachable]

Supervision/Attestation

(Include only if performed by a trainee under supervision.)

• Trainee: [Name, role]
• Supervising Clinician: [Name, credentials]
• Attestation: [Supervision level and statement of presence/participation]