Weekly Pressure Injury Wound Assessment

This template captures the weekly clinical status of a pressure injury: assessment timing, wound location, stage, size, undermining or tunneling, wound bed tissue, drainage, odor, periwound condition, pain, and response to treatment. It also records whether the wound is improving, stable, or worsening and whether the provider was notified for deterioration or critical findings. Use it as a repeatable audit trail for trend review, not as a one-time intake form.

It should be completed by a qualified clinician or wound-care staff member authorized by facility policy, such as an RN, wound nurse, or provider. The signer should have the credentials needed to assess wound status and escalate changes appropriately. If your workflow allows delegated data entry, the final review and sign-off should still belong to the licensed clinician responsible for the assessment.

Use it weekly for any active pressure injury that requires ongoing monitoring, or more often if your care plan, facility policy, or clinical condition requires closer follow-up. If the wound is rapidly changing, has new drainage or odor, or shows signs of deterioration, do not wait for the next weekly cycle to document and escalate. The template is designed to compare one week against the prior assessment so trends are visible.

This template supports documentation practices commonly expected under healthcare quality programs, accreditation surveys, and facility policies aligned with clinical recordkeeping standards. It is also useful for internal quality audits, wound-care protocols, and continuity of care. If your organization follows specific nursing documentation rules, pressure injury prevention policies, or payer requirements, map the fields to those local standards before rollout.

Common mistakes include recording only a stage without measurements, omitting undermining or tunneling when present, and using vague terms like 'looks better' instead of describing the tissue and drainage. Another frequent issue is failing to compare against the prior weekly assessment, which makes it hard to prove improvement or deterioration. The form works best when each field is completed with observable, repeatable details.

Yes. You can add fields for dressing type, offloading method, wound location diagrams, Braden score, photos, or provider orders if your workflow needs them. Long-term care, home health, acute care, and skilled nursing facilities often customize the sign-off and escalation fields differently. Keep the core weekly trend fields intact so the assessment remains comparable over time.

An ad hoc note often captures the current appearance but misses the trend data needed to judge healing or deterioration. This template forces consistent weekly comparisons across stage, size, drainage, pain, and treatment response, which makes handoffs and audits easier. It also reduces the chance that a critical change is overlooked because the same questions are asked every time.

Only if your facility policy requires photo documentation or if the care team uses images to support trend review. When photos are allowed, they should be captured consistently and stored according to privacy and record-retention rules. The template leaves room for that decision without making photos mandatory in every case.