Wound Care Information Standard

Wound care is a critical aspect of healthcare that affects people of all ages. The National Wound Care Strategy Programme 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 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‚Äôs 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‚Äôs care. 


ISN released: Nov 2023

The Wound Care Information Standard has now achieved ISN Status following rigorous quality assurance by the NHS Data Alliance Partnership Board. Find out more about ISN status here.

About this standard

The standard defines the information record content for the management of wound care.‚ÄĮ It is designed to support the professionals,¬†those providing care as well as the person themselves, and to support the national wound care strategy.‚ÄĮThe 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

Personal details should include information such as the person demographics, safeguarding, risks, alerts, legal information, individual requirements and About Me. 

 These sections are commonly used in other PRSB standards including the PRSB’s Core Information Standard where more details are available.

General health information and relevant history

General health information including information such as medications, allergies, test and examination results, social context, problems (includes conditions), procedures and therapies and relevant medical, surgical and mental health history. These sections are commonly used in other PRSB standards including the PRSB’s Core Information Standard where more details are available.

Circle of care

Details for the professional and personal contacts involved in the care of the person. 

These are defined in other PRSB standards including the PRSB’s Core Information Standard where more details are available under the sections professional contacts, personal contacts and GP details.

The domains‚ÄĮare 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.‚ÄĮThe 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 table here shows a summary view of the Wound Care Information Standard and should be viewed in conjunction with the information below the table.

Table key:
M ‚Äď Mandatory information must always be included
R ‚Äď Should be included where the information is available

NameConformanceDescription
Wound assessment and treatment domain  
RisksRRisk factors for delayed healing: Including diseases and conditions that affect wound healing.
Wound assessment and treatmentRThis section contains the assessments, observations and treatments that the health care professional makes about wounds
    Contacts with professionalsMThe details of each contact the person has with a professional including who, how, where and anyone accompanying the person
    Baseline informationMInitial description, mapping and number of wounds that exist at the start of the wound care episode.  Includes:
all relevant diagnoses, symptoms, conditions, problems, and issues relating to the cause or diagnosis of the wound
Bodymap, date, site, wound desription & surgical wound specific information for each wound
    Wound assessmentRPeriodic assessments (with indicator for 1st assessment), both structured and unstructured, as recommended by best clinical practice (NWCSP). Includes:
Structured assessments such as TIMES, SINBAD or others such as frailty assessments
Wound shape & measurements, surrounding skin description, image, complications
Specific vascular assessments and ABPI  and toe pressure index
Pressure ulcer category
Approximation of wound edges for surgical wounds
    Wound observationsRObservations relating to the wound care episode
        Clinical observationsRObservations that health care professionals make.  Includes; pain, signs and symtoms of infection, exudate, dressing performance, odour, pulse, joint mobolity. oedema, sensitivity and sensation, temperature, nutrition and hydration, surgical wound specific observastions
        Person observationsRObservations noted and reported by the person
    Wound and skin care treatmentRThis section allows for the recording of any wound treatments that the care professional delivers to the person. This includes: the application of wound care products (dressings, lotions etc.),  any procedures undertaken, such as debridement, and any therapies provided along with consent for treatment, planned actions for the professional or the person,  information and advice given, and details of any future appointments
    Wound care episode outcomeRThis includes a clinical summary and indicator for if the wound is healed or remains open.
Treatment plan domain¬†This domain uses the existing Personalised Care and Support Plan (PCSP) standard along with the person’s preferences.¬† The care and support plan section of the PCSP is used for the person’s overall (hollistic) strengths, needs, goals and actions & activities.¬† An additional support plan can be used for the specific medical treatment plan for wound care.
Person preferences and treatment objectivesRPerson’s and carer’s priorities and expectations for treatment, these change over time, NB, person and carer’s objectives may not be consistent, including practicalities, environmental and logistical considerations (transport etc.) These include  social preferences, for example being mobile for daughters wedding, statement of care preferences, for example, reduction of odour or visibility of dressings, experience from previous treatments, previous equipment experience, preferred communication method
Care and support planRThis records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.  It is based around the hollistic needs and goals of the person.
    StrengthsRAny strengths and assets the person has relating to their goals and hopes about their health and well-being.
    Needs, concerns or problemsRDetails of the person needs, concerns or problems.
Needs are defined as health or care deficits identified by the person with their carer(s) or professionals and are the motivations/indications for healthcare activities. Examples of needs could be (e.g.) ‚Äėto dress myself‚Äô; ‚Äėto better understand what my various medications are for‚Äô; ‚Äėto reduce pain in my knees‚Äô. Concerns are gathered information to support continuity of care for a person. Concerns can include biological, psychological or social concerns. They may include things the person or carer is concerned about. For example, a person‚Äôs concern may be ‚Äėthe quality of social housing‚Äô; a professional‚Äôs concern could be ‚Äėhigh blood pressure Problems are defined as: A condition that needs addressing and is important for every professional to know about when seeing a person. Problems may include diagnoses (e.g. COPD; diabetes), symptoms (e.g. joint pain; breathlessness), disabilities (e.g. sensory impairments; amputations), health, social and behavioural issues. Problems recorded here may link to the problem list held in a shared care record or GP system for a person using services.
        Goals and hopesRThe overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.  It includes status and outcomes for each goal.
¬†¬†¬†¬†¬†¬†¬†¬†Actions and activitiesRActions or activities the person or others plan to take to achieve the person’s goals and the resources required to do this.¬† This includes who, when, suggested strategies for potential problems, status, the person’s confidence to carry out the action.¬† It may also include stage goals.
    Care funding sourceRA reference to the funding source and any conditions or limitations associated.
    Other care planning documentsRReference other care planning documents, including the type, location and date.  This may include condition-specific plans, advance care plans, end of life care plan, etc.
    Agreement and review detailsRIndicates whether the plan was discussed and agreed with the person or legitimate representative.  Includes the date last updated, next review date and who is responsible for review
Additional support plansRAdditional support plans
    Additional support plan contentRThis is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. For wound care this is likley to include the medical treatment plan such as frequency of dressing changes and assessments, wound bed preparation and products to be used, and pain management.
    Review detailsRThe date last updated, next review date and who is responsible for review
Contingency plansRThese are the things to do and people to contact, should an individual’s health or other circumstances get worse.
    Trigger factors Signs to watch out for that may indicate a significant change in health or other circumstances. These could include physical health conditions, environmental factors, or mental health problems, (e.g. feeling anxious)
    What should happenRGuidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the person. A statement of suggested actions. Usually expressed as: in the event of X do Y.
    Who should be contactedRWho should be contacted in the event of significant problems or deterioration in health or wellbeing. e.g. name, role and contact details.
    Coping strategiesRDetails of coping strategies used
¬†¬†¬†¬†Relapse indicators / early warning signsRDetails of the relapse indicators for the person. These may also be called ‘early warning signs’
    Advance statementRWritten requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
    Anticipatory medicines/equipmentRMedicines or equipment available that may be required in specific situations and their location.
    Agreement and review detailsRIndicates whether the plan was discussed and agreed with the person or legitimate representative.  Includes the date last updated, next review date and who is responsible for review
Supported Self Care (Supported Self Management) domain  
Documents (including correspondence, audio and images)RThis section includes details for documents and images related to the person, so that a system SHOULD be able to receive and display images of wound and limbs taken at home on their personal device.
Structured educationRDetails of the person’s participation in education.


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 ‚Äúcontact with professionals‚ÄĚ for each contact. This is likely to be followed by a ‚Äúbaseline assessment‚ÄĚ, ‚Äúclinical observations‚ÄĚ, and initial treatments. The baseline assessment is then likely to be used to develop a treatment plan through discussion with the individual of their ‚ÄúAbout Me‚ÄĚ information, gathering their ‚ÄúPerson preferences‚ÄĚ and considering the relevant treatments. 

The treatment plan would be added to their ‚Äúpersonalised care and support plan‚ÄĚ using the ‚Äúcare and support plan‚ÄĚ section for their needs, goals and actions and if needed an ‚Äúadditional support plan‚ÄĚ for the details of the medical treatment. A ‚Äúcontingency plan‚ÄĚ (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.

Mandatory

The information must be recorded.

Required

If it exists, the information must be recorded.

Optional

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: November 2023
Version: V1.0

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

Wound assessment and treatment

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

 

Supporting documentation

  • Information Standards Notice (ISN)
  • Release notes V1.0
  • 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
  • New call-to-action
  • 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 date: Oct-Dec 2026

This is the default 3 year review period for PRSB standards. Earlier updates may be made if there are significant updates to make. 

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 Jan 2024.


Endorsement

The following key stakeholders have endorsed the standard:

  • Royal College of Nursing
  • Royal College of Podiatrists
  • Queens Nursing Institute
  • Society for Vascular Nurses
  • Society of Tissue Viability
  • Vascular Society
  • Homecare association
  • Independent Healthcare Provider Network
  • Institute of health records and information management