Wound Care SOAP Notes for Nurses
Master wound documentation with proper staging, measurements, and treatment plans. Plus, learn how AI can automate your wound care notes.
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Why Wound Documentation Matters
Accurate wound care documentation is essential for continuity of care, reimbursement, and legal protection. Poor wound documentation can lead to:
- Delayed healing - Missed changes in wound status can delay appropriate interventions
- Denied reimbursement - Medicare and insurance require specific documentation for wound care supplies and treatments
- Legal liability - Incomplete documentation leaves you vulnerable in malpractice claims
- Communication gaps - Other providers need accurate wound descriptions to provide consistent care
Pro Tip
Document wounds on admission and compare against discharge to demonstrate healing progress and justify the care provided.
Key Elements of Wound Assessment Notes
A complete wound assessment note should include the following components:
1. Location
Document the anatomical location precisely. Use anatomical landmarks and specify laterality (left/right).
- "Right lateral malleolus" not just "ankle"
- "Left sacral area at 3 o'clock position" for specific orientation
- "Posterior heel" rather than "foot"
2. Wound Measurements
Measure wounds consistently using the "clock method" with the patient's head at 12 o'clock:
- Length - Longest measurement head to toe (12 to 6 o'clock)
- Width - Longest measurement side to side (3 to 9 o'clock)
- Depth - Deepest point using a sterile cotton-tipped applicator
- Tunneling - Direction and depth (e.g., "Tunneling 2.5 cm at 3 o'clock")
- Undermining - Extent in clock positions (e.g., "Undermining from 9 to 12 o'clock, 1.5 cm deep")
3. Wound Bed Description
Document the tissue types present and their approximate percentages:
- Granulation tissue - Red, beefy, granular appearance (healthy healing)
- Slough - Yellow, tan, or gray moist tissue (non-viable)
- Eschar - Black or brown hard, dry necrotic tissue
- Epithelial tissue - Pink/pearly tissue at wound edges (new skin growth)
4. Wound Edges and Periwound
- Edge characteristics: attached, rolled, epithelializing, macerated
- Periwound skin: intact, erythematous, indurated, macerated, excoriated
- Note any signs of infection: warmth, increased redness, swelling
5. Exudate
- Type - Serous (clear), sanguineous (bloody), serosanguineous (pink), purulent (yellow/green)
- Amount - None, scant, small, moderate, large, copious
- Odor - None, mild, foul (may indicate infection)
6. Pain Assessment
Document pain level at rest and during dressing changes using a 0-10 scale.
Pressure Ulcer Staging Guide
Use the National Pressure Injury Advisory Panel (NPIAP) staging system for pressure injuries:
| Stage | Description | Documentation Example |
|---|---|---|
| Stage 1 | Non-blanchable erythema of intact skin | "Stage 1 pressure injury to left heel, 2x2 cm area of non-blanchable erythema, skin intact" |
| Stage 2 | Partial-thickness skin loss with exposed dermis; may present as intact or ruptured blister | "Stage 2 pressure injury to sacrum, 3x2.5 cm, shallow open ulcer with pink wound bed, no slough" |
| Stage 3 | Full-thickness skin loss; adipose may be visible; slough and/or eschar may be present | "Stage 3 pressure injury to right trochanter, 4x3x1.5 cm, 50% granulation, 50% slough" |
| Stage 4 | Full-thickness tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone | "Stage 4 pressure injury to left ischium, 5x4x2 cm, exposed muscle visible, tunneling 3 cm at 6 o'clock" |
| Unstageable | Full-thickness tissue loss; base obscured by slough and/or eschar | "Unstageable pressure injury to right heel, 3x3 cm, 100% dry eschar, unable to assess depth" |
| DTPI | Deep Tissue Pressure Injury - intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration | "Suspected DTPI to left heel, 4x3 cm area of deep purple discoloration, skin intact, boggy to palpation" |
Important
Pressure injuries do NOT reverse stage as they heal. A Stage 4 that is healing is documented as "Stage 4 pressure injury, healing" not downgraded to Stage 3.
Wound Care SOAP Note Examples
Pressure Ulcer Assessment - Stage 3
Patient with sacral pressure ulcer receiving wound care in home health setting.
S - Subjective
Patient reports pain level of 4/10 at wound site at rest, increasing to 6/10 during dressing changes. States wound "feels better than last week" and denies fever, chills, or increased drainage. Caregiver reports patient has been repositioned every 2 hours as instructed and using pressure-relieving mattress.
O - Objective
Wound Assessment:
Location: Sacral area
Stage: 3
Measurements: 4.2 cm (L) x 3.8 cm (W) x 1.2 cm (D) - decreased from 4.5 x 4.0 x 1.5 cm on previous visit
Wound Bed: 70% red granulation tissue, 30% yellow slough (improved from 50/50 last visit)
Edges: Attached, beginning epithelialization noted at 12 o'clock position
Periwound: Intact, no erythema or induration
Exudate: Moderate serosanguineous, no odor
Tunneling/Undermining: None
Vitals: Afebrile, BP 128/78, HR 72
Wound care performed: Cleansed with NS, sharp debridement of loose slough, hydrogel applied, foam dressing secured with tape.
Location: Sacral area
Stage: 3
Measurements: 4.2 cm (L) x 3.8 cm (W) x 1.2 cm (D) - decreased from 4.5 x 4.0 x 1.5 cm on previous visit
Wound Bed: 70% red granulation tissue, 30% yellow slough (improved from 50/50 last visit)
Edges: Attached, beginning epithelialization noted at 12 o'clock position
Periwound: Intact, no erythema or induration
Exudate: Moderate serosanguineous, no odor
Tunneling/Undermining: None
Vitals: Afebrile, BP 128/78, HR 72
Wound care performed: Cleansed with NS, sharp debridement of loose slough, hydrogel applied, foam dressing secured with tape.
A - Assessment
Stage 3 sacral pressure injury demonstrating positive healing trajectory with 20% reduction in wound dimensions and improved granulation tissue. Pain controlled at acceptable level. Patient and caregiver compliant with pressure redistribution protocol. No signs or symptoms of infection.
P - Plan
1. Continue current wound care regimen: NS cleansing, hydrogel to wound bed, foam dressing q3 days and PRN
2. Continue pressure redistribution with repositioning q2h and pressure-relieving mattress
3. Reinforce nutrition education - adequate protein and hydration for wound healing
4. Next wound care visit in 3 days
5. Contact MD if signs of infection develop (increased redness, warmth, purulent drainage, fever)
2. Continue pressure redistribution with repositioning q2h and pressure-relieving mattress
3. Reinforce nutrition education - adequate protein and hydration for wound healing
4. Next wound care visit in 3 days
5. Contact MD if signs of infection develop (increased redness, warmth, purulent drainage, fever)
Surgical Wound - Post-Operative Day 5
Skilled nursing visit for patient post abdominal surgery with healing incision.
S - Subjective
Patient reports incisional pain 3/10, well-controlled with prescribed medication. Denies fever, increased redness, or drainage from incision site. States she has been following activity restrictions and using abdominal binder as instructed.
O - Objective
Surgical Incision Assessment:
Location: Midline abdominal incision
Length: 15 cm
Closure: Staples x 18, all intact
Wound Edges: Well-approximated throughout
Drainage: Scant serosanguineous at inferior aspect
Periwound: Mild erythema (0.5 cm) along incision line, no induration or warmth
Signs of Infection: None - no purulence, no wound dehiscence, no fever
Vitals: T 98.4F, BP 122/74, HR 76, RR 16
Wound care: Incision cleansed with NS, steri-strips applied to areas of tension, dry sterile dressing applied.
Location: Midline abdominal incision
Length: 15 cm
Closure: Staples x 18, all intact
Wound Edges: Well-approximated throughout
Drainage: Scant serosanguineous at inferior aspect
Periwound: Mild erythema (0.5 cm) along incision line, no induration or warmth
Signs of Infection: None - no purulence, no wound dehiscence, no fever
Vitals: T 98.4F, BP 122/74, HR 76, RR 16
Wound care: Incision cleansed with NS, steri-strips applied to areas of tension, dry sterile dressing applied.
A - Assessment
Surgical incision healing by primary intention without complication. Mild periwound erythema consistent with normal inflammatory phase of healing. Patient demonstrating appropriate post-operative precautions and pain management.
P - Plan
1. Continue daily dressing changes with NS cleansing and dry sterile gauze
2. Staple removal scheduled with surgeon on POD 10-14
3. Continue activity restrictions and abdominal binder use
4. Educate on signs of infection requiring immediate medical attention
5. Next SN visit in 2 days for wound assessment and staple count
2. Staple removal scheduled with surgeon on POD 10-14
3. Continue activity restrictions and abdominal binder use
4. Educate on signs of infection requiring immediate medical attention
5. Next SN visit in 2 days for wound assessment and staple count
Diabetic Foot Ulcer
Weekly wound care for patient with diabetes and chronic foot ulcer.
S - Subjective
Patient reports no pain at ulcer site secondary to peripheral neuropathy. States blood sugars have been "running high" this week (180-220 fasting). Denies wearing prescribed offloading boot consistently, admits to walking barefoot at home. No new complaints of fever or chills.
O - Objective
Wound Assessment:
Location: Plantar surface, right foot, 1st metatarsal head
Type: Neuropathic diabetic foot ulcer
Measurements: 2.0 cm (L) x 1.8 cm (W) x 0.3 cm (D) - unchanged from last visit
Wound Bed: 40% pale granulation tissue, 60% fibrinous slough
Edges: Callused, rolled edges present
Periwound: Callus formation circumferentially, no cellulitis
Exudate: Scant serous
Pulses: Dorsalis pedis and posterior tibial palpable bilaterally
Sensation: Absent to 10g monofilament bilateral feet
Vitals: Afebrile, BP 142/88, Fasting glucose per patient 195 mg/dL
Wound care: Callus debrided, wound cleansed with NS, enzymatic debriding agent applied, foam dressing with offloading pad applied.
Location: Plantar surface, right foot, 1st metatarsal head
Type: Neuropathic diabetic foot ulcer
Measurements: 2.0 cm (L) x 1.8 cm (W) x 0.3 cm (D) - unchanged from last visit
Wound Bed: 40% pale granulation tissue, 60% fibrinous slough
Edges: Callused, rolled edges present
Periwound: Callus formation circumferentially, no cellulitis
Exudate: Scant serous
Pulses: Dorsalis pedis and posterior tibial palpable bilaterally
Sensation: Absent to 10g monofilament bilateral feet
Vitals: Afebrile, BP 142/88, Fasting glucose per patient 195 mg/dL
Wound care: Callus debrided, wound cleansed with NS, enzymatic debriding agent applied, foam dressing with offloading pad applied.
A - Assessment
Diabetic foot ulcer with stalled healing progression. Contributing factors include non-compliance with offloading footwear and suboptimal glycemic control. No clinical signs of infection at this time. Peripheral neuropathy confirmed with absent protective sensation.
P - Plan
1. Continue weekly wound care with callus debridement, NS cleansing, enzymatic debriding agent, and foam dressing
2. Reinforced critical importance of offloading boot wear at all times when weightbearing
3. Contacted MD regarding elevated blood glucose - awaiting medication adjustment
4. Diabetes educator referral placed for glycemic management education
5. Patient education on daily foot inspections and never walking barefoot
6. If no improvement in 2 weeks, will recommend vascular studies and wound care consult
7. Next visit in 7 days
2. Reinforced critical importance of offloading boot wear at all times when weightbearing
3. Contacted MD regarding elevated blood glucose - awaiting medication adjustment
4. Diabetes educator referral placed for glycemic management education
5. Patient education on daily foot inspections and never walking barefoot
6. If no improvement in 2 weeks, will recommend vascular studies and wound care consult
7. Next visit in 7 days
Common Wound Documentation Mistakes to Avoid
Do This
- Measure wounds consistently using the clock method
- Document tissue percentages in wound bed
- Include all SOAP components every visit
- Photograph wounds with ruler when possible
- Document patient/caregiver education provided
- Note comparison to previous measurements
Avoid This
- Vague descriptions like "wound looks better"
- Missing measurements or incomplete assessments
- Inconsistent measurement technique between visits
- Failing to document wound care interventions
- Not noting patient compliance or barriers
- Copy-pasting previous notes without updates
Documentation Tip
If a wound is not improving as expected, document your clinical reasoning and the actions you're taking (contacting MD, adjusting treatment, recommending specialty consult).
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