Wound Care Assessment & Documentation Checklist
Comprehensive wound assessment and documentation including wound measurements, tissue characteristics, and treatment planning.
- Industry: Healthcare
- Frequency: Per dressing change
- Estimated Time: 15-20 minutes
- Role: Nurse/Wound Care Specialist
- Total Items: 32
- Compliance: WOCN Guidelines, NPUAP/EPUAP Guidelines, CMS Documentation
Wound Measurements
Size documentation
- Length documented (cm)?
- Width documented (cm)?
- Depth documented?
- Undermining assessed and documented?
- Tunneling assessed and documented?
Wound Bed Tissue
Tissue characteristics
- Granulation tissue percentage?
- Slough percentage documented?
- Eschar percentage documented?
- Epithelialization noted?
Drainage/Exudate
Wound drainage
- Amount documented (none, scant, moderate, copious)?
- Type documented (serous, sanguineous, purulent)?
- Odor assessed?
Periwound Skin
Surrounding skin
- Periwound skin assessed?
- Skin intact or macerated?
- Erythema present?
Treatment Plan
Care provided
- Wound cleansing documented?
- Dressing type documented?
- Dressing change frequency documented?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Related Healthcare Checklists
- Pre-Operative Nursing Assessment Checklist
- Post-Operative PACU Assessment Checklist
- Specimen Labeling Verification Checklist
- Sepsis Screening Protocol Checklist
- Clinical Alarm Management Checklist
- Medication Error Prevention Checklist
- Patient Identification Verification Procedure Checklist
- Safe Patient Handling and Mobility Checklist
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Why Use This Wound Care Assessment & Documentation Checklist?
This wound care assessment & documentation checklist helps healthcare teams maintain compliance and operational excellence. Designed for nurse/wound care specialist professionals, this checklist covers 32 critical inspection points across 8 sections. Recommended frequency: per dressing change.
Ensures compliance with WOCN Guidelines, NPUAP/EPUAP Guidelines, CMS Documentation. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Wound Care Assessment & Documentation Checklist cover?
This checklist covers 32 inspection items across 8 sections: Wound Measurements, Wound Bed Tissue, Drainage/Exudate, Periwound Skin, Treatment Plan, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed per dressing change. Each completion takes approximately 15-20 minutes.
Who should use this Wound Care Assessment & Documentation Checklist?
This checklist is designed for Nurse/Wound Care Specialist professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.