Bates-Jensen Wound Assessment Tool (BWAT) Documentation

This template covers the core BWAT documentation workflow: assessment context, wound characteristics, total score, trend, and follow-up sign-off. It is designed to capture the observable wound findings that support a consistent score and a clear comparison to the prior assessment. Use it as the record of what was seen, scored, and changed over time.

For an active wound, this template is built for at least weekly reassessment so trend data stays current. More frequent documentation may be appropriate when the wound is changing quickly, after a treatment change, or when a clinician needs closer monitoring. The key is to keep the cadence consistent enough to show whether the wound is improving, stable, or worsening.

A trained clinician or wound care staff member should complete the assessment, since the score depends on consistent observation and interpretation. The same role should ideally use the same method across visits to reduce variation. If multiple staff members document, they should follow the same scoring guidance and facility workflow.

BWAT itself is a clinical documentation tool, not a law or standalone regulatory mandate. It can support quality management, wound surveillance, and care planning in settings that follow clinical documentation standards, accreditation expectations, or internal wound protocols. Facilities should align its use with their policies and applicable healthcare documentation requirements.

Common mistakes include leaving out the prior score, documenting vague wound descriptions instead of observable findings, and skipping the trend interpretation. Another frequent issue is inconsistent reassessment timing, which makes the score hard to compare. This template helps prevent those gaps by prompting the user to record the context, score, and follow-up in one pass.

Yes. You can adapt the notes fields, follow-up section, or workflow prompts for pressure injuries, surgical wounds, diabetic foot ulcers, or other wound types treated in your setting. The scoring structure should stay consistent if you want the trend data to remain comparable across visits. Customization is most useful for adding facility-specific treatment notes or escalation triggers.

It can be used as a structured paper form, a digital checklist, or a data-entry template that feeds into an EHR or wound registry. The main benefit is that it standardizes the fields needed for trend tracking before the information is entered elsewhere. If your workflow includes photos, measurements, or care-plan updates, this template can sit alongside those records.

Document the change clearly in the trend and follow-up sections, then record the corrective action or treatment change taken. If your facility uses escalation criteria, note whether the wound was referred, re-evaluated, or reviewed by a higher-level clinician. The template is meant to make worsening visible quickly so the next step is not missed.