With the exception of surgical wounds, wound care normally starts with a baseline assessment of the wound and the person. The wound assessment and treatment section of this standard allows for recording details of the “contact with professionals” for each contact. This is likely to be followed by a “baseline assessment”, “clinical observations”, and initial treatments. The baseline assessment is then likely to be used to develop a treatment plan through discussion with the individual of their “About Me” information, gathering their “Person preferences” and considering the relevant treatments. 

The treatment plan would be added to their “personalised care and support plan” using the “care and support plan” section for their needs, goals and actions and if needed an “additional support plan” for the details of the medical treatment. A “contingency plan” (also known as an escalation plan) can also be created if appropriate.

It is recognised that for surgical wounds, the treatment plan may be developed pre-surgery, and the assessment and treatment will only apply if wound complications occur post-surgery.

All further contacts with professionals would then be recorded in a similar way along with assessments, observations and treatments as deemed professionally appropriate. The standard supports professional guidance by allowing consistent information to be recorded with the potential for prompts for the information recorded in assessments, observations and treatments.

The supported self-care (self-management) section enables the recording of any self-care that the person with a wound may do, and for the person to record documents or images which can be uploaded to a clinical system or patient record.