Wound Care Information Standard – Draft

Wound care is a critical aspect of healthcare that affects people of all ages. The National Wound Care Strategy Programme (NWCSP) seeks to improve care for people with wounds by addressing the unwarranted variation in wound care services, underuse of evidence-based practices and overuse of ineffective practices.  

The NWCSP’s goal is to reduce pain and suffering for patients, improve healing rates, prevent wounds from happening or coming back, and use healthcare resources more efficiently. PRSB’s Wound Care Information Standard will help to support this goal by encouraging the consistent recording of information which can be shared with all those involved in the person’s care. 

About this standard

The standard defines the information record content for the management of wound care.  It is designed to support the professionals, those providing care as well as the person themselves, and to support the national wound care strategy. The standard has three specific domains which support the management of wound care. These are shown here: 

Wound assessment and treatment

Wound cause(s) and baseline information, wound assessment and treatments.

Treatment plan

Intended treatment regime, escalation pathway and person preferences.

Supported self-care (self-management)

Information provided to, or recorded by, the person during their wound care treatment.

There are three further domains for information which should be available to those providing care, personal details, relevant history and circle of care as shown below: 

Personal details

Person details, safeguarding, risks, individual requirements, legal information and About Me.

General health information and relevant history

General health information including information such as medications, allergies, social context and relevant history.

Circle of care

Contact details for care professionals and personal carers involved in the care of the person.

The domains are mostly built from existing PRSB components used in other standards with a few new sections and elements, which helps ensure consistency in the use and sharing of information. The treatment plan uses the existing Personalised Care and Support Plan (PCSP) Standard. This is a person-centred plan, developed with the person to address their overall needs and goals.  

In scope

The standard covers the assessment, diagnosis, treatment, ongoing care and prevention of the wounds across all health and care settings for three areas of wound care;  

  • Lower limb (leg and foot) wounds
  • Pressure ulcers
  • Surgical wound complications  

The standard is UK wide and is for adults and children.  

Out of scope

  • Wound types not specified above, including those caused by external factors such as new trauma and burns (although it may work for these).
  • Management of arterial and peripheral vascular disease. While leg wounds often result from peripheral venous or arterial disease, prevention and management of vascular disease is beyond the scope of this standard.
  • Management of Lymphoedema. While leg wounds may result from lower limb lymphoedema, management of lymphoedema is beyond the scope of this standard.

How the standard should be used

The information below should be read in conjunction with the wound care information standard summary table shown to the right here. 

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.

Mandatory, required and optional

All elements in the information standard are defined as either Mandatory, Required or Optional. Very few elements are mandatory, many are required and these only need to be entered when they are collected or known, and can be left blank when they are not appropriate for that occasion.


The information must be recorded.


If it exists, the information must be recorded.


A local decision is made as to whether the information is recorded

Implementing the standard

The information standard defines the data that should be recorded to support care professionals in their delivery of high quality care. IT system suppliers are expected to build or customise their clinical systems to allow the recording of this data. Systems will be a mix of specialist wound care management systems and more general electronic patient record systems. Care professionals need to be aware of the standard but do not need to have a complete, in depth understanding of the detail of the standard’s information model. Care professionals should be reassured that their system has implemented and operates in accordance with the information standard. It is recommended that those responsible for clinical systems check if their suppliers have implemented the standard.

Examples of the standard in use

To give a clearer idea of how the standard works in practice, PRSB are creating examples to show how the standard is intended to be used in practice. The examples are currently being developed and will be published soon.

Current release

Current release
Date: April 2023
Version: Draft V0.4 (pending endorsement and ISN approval)

The standard comprises 3 domains. The links below show the standard in three different formats.

Wound assessment and treatment

  • New call-to-action
  • New call-to-action
  • New call-to-action
Treatment plan
  • New call-to-action
  • New call-to-action
  • New call-to-action
Supported self-care (self-management)
  • New call-to-action
  • New call-to-action
  • New call-to-action


Supporting documentation

  • New call-to-action
    (Detailed implementation guidance specific to the sections and elements of this standard are included within the information model)
  • New call-to-action
    • New call-to-action (appendix to final report)
  • New call-to-action
  • New call-to-action – draft pending NHSE Clinical Safety Group approval
  • New call-to-action – draft pending NHSE Clinical Safety Group approval
  • Provenance Data Standard
    Provenance data for this standard is now shown in a separate information model which is explained and available on this webpage.

Next release dates:

  • ISN Status (England only): ISN anticipated Aug-23
  • Next release: V1.0 is planned for Autumn 2023 after endorsement and ISN approval.

Further resources

  • IHRIM record correction guidance
    Despite vigilance when filing information in records, mistakes can occur. The Institute of Health Records and Information Management has guidance to support professionals in making corrections following errors.

Implementation support

An implementation toolkit is currently in development and is due to be published in June/July 2023.



Endorsement is in progress with key professional bodies and stakeholders.