Wound Care Template - Home Health Patient Education

Does the patient have any active wound?
- Yes
- No
The wound is located on
Type of Wound
- surgical wound.
- surgical incision.
- diabetic wound.
- pressure necrosis wound.
- pressure ulcer.
- abrasion wound.
- burn wound.
- laceration wound.
- avulsion wound.
- mechanical injury.
- wound suffered from fall.
- drain insertion site.
- arterial ulcer.
- venous ulcer.
- stasis ulcer.
- nonstageable pressure ulcer.
Pressure Ulcer Stage (number only)
Independence with Wound Care
- Patient is independent at performing wound care and is trained on the same.
- Patient can be independent with wound care and needs to be trained.
- Patient is dependent on caregiver assistance for wound dressing change.
- Caregiver is independent at performing wound care and is trained on the same.
- Caregiver can be independent with wound care, but needs to be trained.
- No willing caregiver is available to perform regular wound dressing change.
- Home health staff to perform wound dressing, as ordered.
Was wound care performed today?
- Yes
- No
No Wound Care Today
- Today is not a scheduled wound care day and the old dressing was noted to be intact during the visit.
- Caregiver has already changed the dressing for today.
- SN did not perform wound dressing change today and wound measurements are unknown.
- Wound care orders are not available.
Other reasons for not performing wound care today
Old Dressing Removal
- SN performed hand washing with soap and water before doing the dressing change.Gloves were worn.Old dressing on the wound was removed and discarded according to OSHA guidelines.
Drainage amount
- No noticeable
- Mild
- Moderate
- Heavy
Drainage type
- serous
- serosanguineous
- sanguineous
- mucous
- purulent
Any foul smell noted?
- Foul smell
- No foul smell
The wound is
- open wound
- closed wound
The wound edges are approximated with
- staples
- sutures
- glue
- zipline
Wound Bed Appearance
- Wound bed appeared pink in color and healthy.
- Healthy granulation tissue deposition noted on the surface of wound bed.
- Yellow brown slough noted on the wound bed.
- Wound bed appeared black in color and necrotic.
- The wound is partially scabbed.
Periwound area appearance
- pink and healthy
- pale
- dry and scaly
- blue and cyanotic
Erythema in surrounding tissue
- No noticeable
- Mild
- Moderate
- Severe
Wound Cleanser Used
- sterile normal saline
- vashe
- dermal wound cleanser
- betadine solution
Drying the Wound Site and Surrounding Skin
- The wound site and surrounding skin were gently blot dried using 4 x 4.
Wound Measurements
- Wound measurements were taken using sterile Q-tips.
- Wound was poorly circumscribed and so, difficult to measure.
- Multiple clusters of wounds noted and are difficult to measure.
Incision Line Measurements
Wound Measurements (dimensions)
Tunneling (For example- 4 cm in 3’o clock position)
Undermining (For example- 2'o clock to 8'o clock position)
Skin Prep Application
- Skin prep was applied to prevent damage of the surrounding skin by adhesives.
Please specify antibacterial ointment applied (name only)
Was wound vac fixed today?
- Yes
- No
Primary Wound Dressing
- 4x4 ;
- sterile gauze ;
- bordered gauze ;
- promogran ;
- moist hydrofera blue ;
- xeroform gauze dressing ;
- aquacel silver ;
- mepilex dressing ;
- suresite ;
- transparent film dressing ;
- Telfa ;
Other primary wound dressing
Wound Packing
- sterile gauze ;
- promogran ;
- moist hydrofera blue ;
- xeroform gauze ;
- aquacel silver ;
- Iodoform packing gauze ;
- sorbact ribbon ;
- Calcium Alginate ;
- Collagen ;
Other wound packing
Secondary Wound Dressing
- 4x4 ;
- sterile gauze ;
- bordered guaze ;
- promogran ;
- moist hydrofera blue ;
- xeroform gauze ;
- aquacel silver ;
- Calcium Alginate ;
- Mepilex silver ;
- Mepilex foam dressing ;
- Heel foam ;
- Medihoney ;
- Hydrogel dressing ;
- Hydrocolloid dressing ;
- Suresite ;
- Transparent film dressing ;
- Telfa ;
Other secondary wound dressing
Securing the Wound Dressing
- paper tape ;
- medipore tape ;
- Kerlix roll ;
- ACE wrap ;
- coban ;
- compression wraps ;
Other wound securing material
Wound Vac Dressing Change Summary
- Sterile foam was packed into the wound site. Foam is secured in place with a layer of tegaderm. A hole was cut into tegaderm and drainage tube was attached to it. This was further secured with tegaderm to prevent any leaks. The other end of drainage tube was connected to the pump and pump was restarted. No alerts or alarms noted.
Wound Vac Pressure in mm Hg (number only)
Wound vac drainage amount
- No noticeable
- Mild
- Moderate
- Heavy
Wound vac drainage type
- serous
- serosanguineous
- sanguineous
- mucous
- purulent
Was canister changed today?
- Yes
- No
Any signs and symptoms of wound infection noted today?
- Yes
- No
Pain level reported by patient during the wound care (number only)

Please select only fields that are applicable. None of the information is mandatory on this template.

Wound Care