Wound Care Progress Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Wound Care Note

Patient Identification:
[Patient name, age, gender, relevant medical history]

History of Present Illness:
[Description of wound onset, mechanism of injury, duration, associated symptoms, previous treatments]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Allergen and reaction]

Social History:
(hyphenated list)
- [Tobacco use]
- [Alcohol use]
- [Recreational drug use]
- [Occupation]
- [Living situation]

Wound Assessment:
(hyphenated list)
- [Location of wound]
- [Size (length x width x depth in cm)]
- [Shape]
- [Wound bed appearance (granulation, slough, eschar)]
- [Exudate (type, amount, odor)]
- [Surrounding skin (erythema, edema, induration)]
- [Signs of infection (warmth, tenderness, purulence)]
- [Pain (severity, character)]
- [Other findings (e.g., tunneling, undermining, exposed structures)]

Physical Examination:
(hyphenated list)
- [Vital signs with units] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Relevant system exam findings]

Investigations:
(hyphenated list)
- [Wound cultures]
- [Imaging studies]
- [Laboratory results]

Assessment:
(hyphenated list)
- [Diagnosis and reasoning]
- [Complicating factors (e.g., diabetes, vascular disease)]

Plan:
(hyphenated list)
- [Wound care interventions (cleansing, debridement, dressing type)]
- [Medications (antibiotics, analgesics)]
- [Adjunct therapies (negative pressure, topical agents)]
- [Patient education and counselling]
- [Referrals (e.g., surgery, infectious disease, vascular)]
- [Follow up plan]
- [Return precautions]