Wound-care guide · Referral sources
A practical wound-documentation checklist
Useful wound documentation describes the wound, treatment, patient response and decisions in a consistent format.
Record treatment, supplies and patient tolerance
Name the clinician or team receiving the update
Wound assessment
Use consistent terms and measurement methods.
- Anatomic location and wound type
- Length, width, depth and undermining or tunneling
- Tissue, drainage, odor and surrounding skin
- Pain, temperature, edema and infection concerns
Plan and communication
The note should show what was done and what happens next.
- Treatment completed and products used
- Orders followed or changes requested
- Patient and caregiver instruction
- Follow-up timing, responsible clinician and escalation
Document uncertainty honestlyDo not infer a diagnosis, stage or cause that has not been established by the appropriate clinician.
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