01 / ADAPTABLE OUTLINE
What to document
Wound history & contributors
Site, onset, suspected cause, prior care, pain, drainage, fever, mobility, pressure exposure, diabetes, vascular disease, nutrition, and adherence or caregiver barriers.
Structured wound examination
Length × width × depth in cm using a consistent method; tissue and exposed structures, undermining or tunneling, exudate, odor after cleansing, wound edges, periwound skin, and perfusion when relevant.
Assessment & infection review
Wound type, pressure-injury stage only when applicable and supported, trend versus prior measurements, pain, ischemia or infection concerns, and reasons for tests or referral.
Treatment & reassessment
Cleansing, dressing and frequency, offloading or pressure redistribution, nutrition, analgesia, vascular or specialist review, caregiver instructions, and an explicit follow-up interval.
02 / WORKED EXAMPLE
Follow-up of a sacral stage 2 pressure injury
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
Interval history
A 82-year-old patient with limited mobility is seen for wound follow-up. Nursing reports adherence to the individualized pressure-redistribution plan. The patient reports mild discomfort during dressing changes. No fever or new systemic symptoms are reported. Nutrition and continence support were reviewed.
Wound examination
Sacral wound measures 1.2 × 0.8 × 0.1 cm, compared with 1.5 × 1.0 × 0.1 cm at the prior visit using the same measurement method. There is partial-thickness skin loss with exposed pink dermis, without slough, eschar, visible adipose, undermining, or tunneling. Drainage is scant and serous. Surrounding skin is intact without spreading erythema or warmth.
Assessment & treatment
Healing stage 2 sacral pressure injury, with reduced dimensions and no clinical findings of infection today. Continue gentle cleansing and the selected silicone foam dressing, changing according to drainage, product instructions, and the wound team's order. Maintain individualized repositioning and pressure redistribution; protect surrounding skin from moisture. No systemic antibiotic is prescribed in the absence of clinical infection.
Follow-up & instructions
Document measurements and tissue findings at the next wound review in one week. Nursing will inspect during routine care and notify the clinician sooner for increasing pain, drainage, wound size, spreading erythema, fever, or systemic decline. Escalate promptly for ischemia, rapidly progressive injury, or suspected deep infection. No debridement was performed at this visit.
03 / SETTING-SPECIFIC CARE PLAN
Treatment, monitoring & coordination
Adapt the plan to the patient, care setting, and goals. These prompts do not create orders or imply that care was performed.
Match treatment to the wound
For a pressure injury, select a dressing by tissue condition, exudate, location, pain, and tolerance; include pressure relief and nutrition assessment. Compression for a venous wound requires appropriate vascular assessment and is not a universal wound intervention.
Infection and antibiotics
Do not prescribe systemic antibiotics solely to heal a pressure injury or solely because a wound culture is positive. Assess for clinical infection, spreading cellulitis, sepsis, or osteomyelitis and treat or escalate when indicated.
Procedures and pain
If debridement or another procedure is actually performed, record indication, consent, method, depth and area treated, anesthesia, tolerance, and complications. Document individualized pain treatment and the dressing plan separately; a wound assessment does not establish that a procedure occurred.
A common documentation question
Should all wound visits include an antibiotic or debridement?
No. Document the assessment and actual indication for each intervention. Wound cause, tissue condition, perfusion, clinical infection, patient goals, and healing trajectory determine the plan.