Wound Dressing Change Form
Use this form to document a wound dressing change, wound condition, procedure details, and follow-up instructions.
Patient and Visit Details
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dressing Change Visit
*
Wound Assessment
Wound Location
*
Please Select
Left arm
Right arm
Left leg
Right leg
Foot
Hand
Abdomen
Back
Chest
Buttock
Head/Face
Other
Wound Type
*
Please Select
Surgical incision
Pressure injury
Diabetic ulcer
Venous ulcer
Arterial ulcer
Traumatic wound
Burn
Skin tear
Abscess/drainage site
Other
Wound Size (L x W x D)
*
Wound Appearance
*
Signs of Infection or Complications
Redness
Warmth
Swelling
Increased pain
Purulent drainage
Foul odor
Bleeding
Macération
Dehiscence
None observed
Dressing Change Procedure
Dressing type removed
*
Please Select
Gauze
Foam
Hydrocolloid
Alginate
Alginate with silver
Hydrofiber
Transparent film
Adhesive bandage
Negative pressure dressing
Other
Supplies applied during change
*
Sterile gauze
Antiseptic solution
Saline
Topical ointment
Non-adherent pad
Absorbent pad
Compression wrap
Tape
Protective barrier film
Other
Patient tolerance / pain level
*
No pain
1
2
3
4
5
6
7
8
9
Severe pain
10
1 is No pain, 10 is Severe pain
Wound cleaned or irrigated before redressing?
*
Yes
No
Not applicable
Notable observations during dressing change
Follow-Up and Instructions
Aftercare Instructions or Escalation Notes
*
Follow-Up / Next Dressing Change Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Notes or Concerns
Submit
Should be Empty: