Use when the wound is at or holding its expected trajectory under the current order. Fill the bracketed blanks with the visit’s actual measurements and findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled wound assessment and dressing change completed to a [location] [etiology] wound, NPIAP [stage]. Wound measured [L×W×D cm] with [undermining/tunneling or none], compared to [prior dimensions] on [prior date]: dimensions [decreased/stable]. Wound bed [%] granulation, [%] slough, [%] eschar; exudate [amount/type], [no] odor; periwound [intact/condition]. Pain [score] at rest and [score] with the dressing change, [controlled with current regimen]. Cleansed per order with [solution]; [dressing] applied; offloading/compression [device] in place and effective. The measurement and bed assessment confirm the wound is on its expected healing trajectory and that the current treatment order remains appropriate; no change in plan indicated. Wound care and [offloading/positioning] reinforced with the patient/caregiver, who [teach-back result].
Short form
Skilled assessment + dressing change, [location] [etiology] wound, Stage [x]: [L×W×D cm], [decreased/stable] from [prior]; bed [granulation %]; exudate [amount/type], no odor; periwound intact; pain [score], controlled. [Dressing] per order; offloading effective. Healing on trajectory; plan continued. Care reinforced, teach-back correct.
