Wound Treatment Administration Record

Daily treatment administration record for documenting wound care orders performed, wound status, supplies used, and clinical sign-off.

Record Details

• Record Date
• Shift
• Completed By
  Name and credentials of the staff member completing the record.
• Completion Time

Resident and Wound Identification

• Resident Name
  Use the resident's full name as listed in the chart.
• Medical Record Number
  Optional if your facility uses another unique identifier for chart matching.
• Wound Location
• Wound Type
• Laterality

Ordered Treatment

• Treatment Order
  Enter the current wound care order exactly as prescribed, using minimum necessary detail.
• Treatment Performed
• Reason for Deviation
• Provider Notified

Wound Assessment

• Wound Status
• Drainage Amount
• Drainage Type
• Odor Present
• Peri-wound Condition

Dressing and Supplies

• Dressing Changed
• Dressing Type Applied
• Supplies Used
  List only supplies used for the treatment, such as cleanser, gauze, packing material, or barrier cream.
• Wound Measurement Updated Today

Pain, Tolerance, and Sign-Off

• Pain Score During Treatment
• Treatment Tolerance
• Patient Response / Notes
  Document relevant observations, education provided, or follow-up needs.
• Staff Signature