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Template content
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Wound Care Note Wound Identification - Location, laterality, wound type (surgical, pressure, venous, arterial, diabetic, traumatic, burn), and onset/duration. - Etiology and contributing factors (pressure, edema, neuropathy, vascular disease). Subjective - Pain, odor noticed by patient, drainage on dressings, fever/chills, and functional impact. - Home care adherence and barriers (supplies, caregiver support). Wound Assessment - Size (L × W × D), undermining/tunneling, wound bed (% granulation/slough/eschar), exudate amount/type, periwound skin, edges, and odor. - Signs of infection or osteomyelitis concern; pulses/perfusion and offloading status as relevant. - Photos obtained per policy if applicable (note only; do not invent). Treatment Today - Cleansing, debridement type/extent, cultures, packing, and dressing applied. - Analgesia used for the procedure if any. Assessment - Healing trajectory (improving / stalled / worsening) with brief reasoning. - Infection likelihood and need for systemic antibiotics or imaging. Plan - Dressing frequency and products; compression/offloading/elevation as indicated. - Antibiotics, labs, imaging, or specialty referral (vascular, wound clinic, plastics). - Patient/caregiver education and supply plan. - Follow-up interval and red-flag precautions.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Standardizes wound measurements and characteristics for trend comparison.
- Separates procedure/treatment today from the ongoing care plan.
- Prompts infection, perfusion, and offloading factors that change healing.
- Works for primary care, urgent care, and wound-clinic style documentation.
- 1Chronic wound and ulcer follow-up
- 2Post-procedure or traumatic wound checks
- 3Dressing-change visits in clinic or SNFist workflows
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Wound Left medial ankle venous ulcer, present ~8 weeks; history of chronic venous insufficiency. Compression stockings partially used. Subjective Mild ache end of day; moderate serous drainage. No fever. Lives alone; daughter helps weekends. Assessment Findings Ulcer 2.4 × 1.8 × 0.2 cm; 80% granulation, 20% yellow slough; moderate serous exudate; periwound maceration mild; no tunneling; pulses DP/PT palpable; no spreading cellulitis. Treatment Today Cleaned with saline; sharp debridement of loose slough; foam dressing; multilayer compression applied. No culture indicated today. Assessment / Plan Venous stasis ulcer, slowly improving with better granulation. Continue foam + compression changes 2×/week; elevation counseling. Wound clinic referral if not ≥50% area reduction in 4 weeks. Return 1 week or sooner for fever, spreading redness, or sudden increase in pain/odor.
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