How to Document a Wound Visit in Under Five Minutes

Wound notes pile up when measuring, typing, and re-entering happen at different times. This walkthrough shows how to fold them into one visit, using a mobile workflow built for the bedside.

Before you start

• Open the patient's visit on your phone.
• Make sure the wound is uncovered, cleaned, and well lit.
• Have your usual conversation plan ready. You do not need a special script.

Step by step

1. Capture the wound. Point your phone at the wound and take the image. Length, width, and area are calculated and added to the visit. Read more on point-and-capture wound imaging.
2. Talk through the visit. Describe findings, tissue, drainage, and plan as you normally would with the patient. An AI scribe for wound care listens and drafts the note.
3. Check the vascular and risk details. Confirm that perfusion and other key status items are in the note. This guide on documenting vascular status shows what reviewers look for.
4. Review the SOAP draft. Read each section, correct anything that is off, and add what the scribe could not hear.
5. Sign. Once you approve it, the chart is done before you leave the room.

Common mistakes to avoid

• Signing without reading the draft. AI drafts, you decide.
• Skipping measurements on a wound that looks unchanged.
• Leaving plan-of-care details for later.

For the full picture, see the wound care documentation workflow or how AI charting turns a conversation into a SOAP note.