Wound/Pressure Injury Assessment & Dressing Change Note

Date/Time: [assessment date and time]
Setting: [care setting]
Author: [name and credentials]
Wound-Relevant Allergies: [adhesive, iodine, silver, latex, or other wound care material sensitivities, or None known]

(Keep entries concise. Prefer explicit "None" or "Not assessed—reason" over blank fields. Omit entire subsections that do not apply.)

Indication

[Encounter reason and active wound care order reference if applicable]

Relevant History

[Wound onset and etiology; healing-relevant comorbidities and risk factors; current infection treatment if any. For pressure injuries or high-risk patients, include support surface/offloading and repositioning capability.]

Wound Assessment

(Repeat this section for each wound when multiple wounds are present.)

Wound ID/Location: [wound number, anatomic site with laterality, wound type/etiology, POA status per facility policy]

Stage (pressure injuries only): [Stage 1-4 / Unstageable / Deep Tissue Pressure Injury] (Stage after cleansing; do not reverse-stage as healing occurs; mucosal membrane injuries not numerically staged.)

Measurements: [L × W × D in cm; undermining and tunneling with depth and clock-face location if present; or unable to measure with reason]

Wound Bed: [tissue types with approximate percentages; edge characteristics]

Exudate: [amount, type, odor assessed after cleansing]

Periwound: [integrity, erythema, maceration, edema, induration, warmth]

Pain: [scores at rest/during/after procedure; interventions and effect]

Infection Signs: [local signs observed; if suspected, cultures obtained and provider notification]

Photo: [yes / no] (Per facility policy.)

Care Performed

• Technique: [clean / sterile]
• Cleansing: [solution and method]
• Debridement: [type, tissue removed, hemostasis] (Include only if performed.)
• Topicals/Barriers: [products applied to wound bed and periwound]
• Dressings: [primary dressing; secondary dressing and securement]
• Adjuncts: [compression, offloading, NPWT settings] (Include only if applicable.)
• Next Change: [scheduled dressing change date]
• Variance: [deviation from orders with rationale and notification] (Include only if applicable.)

Response and Plan

• Tolerance: [patient response and post-procedure pain score]
• Complications: [bleeding, skin tear, refusal, or None]
• Education: [dressing care instructions and warning signs reviewed]
• Prevention Plan: [repositioning schedule, offloading, support surface, moisture management] (Include for pressure injuries or high-risk patients.)
• Follow-up: [next reassessment interval and responsible clinician]
• Escalation Triggers: [signs and symptoms warranting earlier contact]