Wound Dressing Application Checklist
Complete this checklist to document and ensure compliance with wound dressing application procedures.
Patient Full Name
*
First Name
Last Name
Patient ID or Medical Record Number
*
Date and Time of Dressing Application
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Staff/Clinician Full Name
*
First Name
Last Name
Wound Location
*
Wound Type
*
Please Select
Surgical
Pressure Ulcer
Diabetic Ulcer
Traumatic
Burn
Other
Reason for Dressing Change
*
Please Select
Routine Change
Soiled Dressing
Wound Assessment
Infection Suspected
Other
Type of Dressing Used
*
Please Select
Gauze
Hydrocolloid
Foam
Alginate
Film
Other
Wound Dressing Procedure Checklist
*
Rows
Completed
Not Applicable
Hand hygiene performed before procedure
1
2
Gloves and PPE worn appropriately
3
4
Old dressing removed and disposed of properly
5
6
Wound assessed for signs of infection
7
8
Wound cleaned as per protocol
9
10
New dressing applied as per protocol
11
12
All waste disposed of safely
13
14
Hand hygiene performed after procedure
15
16
Observations or Notes (e.g., wound appearance, exudate, pain)
Staff/Clinician Signature
*
Submit Checklist
Submit Checklist
Should be Empty: