Keeping a Wound Care Visit Notebook

Why a notebook earns its place

In a few minutes a wound visit can cover measurements, product names, a dressing schedule and the date of the next appointment. Keeping a wound care visit notebook means you do not have to hold all of that in your head. It does not need to be neat. It only needs to be in one place.

A notebook also helps when several people are involved in your care. Your notes are the one record that goes everywhere you go.

Pick a format you will keep using

A spiral notebook, a binder, a running note on your phone or a sheet of paper per visit all work. The right choice is the one you will still be using a month from now.

Keep it where the care happens, with a pen attached.
Use one notebook only, not scraps in three rooms.
Put the date at the top of every entry.
Add a pocket or envelope for discharge papers and supply packing slips.

If several relatives take turns helping, a shared family care log follows the same idea with more than one writer.

The front pages: facts that stay the same

Use the first few pages for information you are asked for again and again:

Phone numbers for the treating clinician’s office, Gateway (314-325-0126), your primary care office, home health agency, pharmacy and supply company. The guide to building your wound care contact list shows what to include.
Where each wound is and roughly when it started. If you have more than one, give each a plain name such as “left heel” or “right shin” and use that name every time.
Allergies, including skin reactions to tape or adhesive.
Your current medication list, or a note saying where it is kept.
The current dressing instructions and the date they were given.

Before each visit: your questions

Start a fresh page and date it. Write your two most important questions at the top.

Below them, jot down what has changed since the last visit:

Pain, drainage, odor or swelling that is new or different
Whether the dressing stayed in place, and how many times it was changed
Supplies that are running low
Falls, illness, or new medications from another clinician
Anything in the plan that has been hard to fit into your day

The guide to describing wound changes to your care team can help you find the words.

During the visit: the agreed plan

You do not have to write down everything. Aim for these:

Who came, by name and role.
Whether the wound is bigger, smaller or about the same. If the clinician shares numbers, copy them (see how wounds are measured).
What changed in the plan, and why.
The dressing instructions: what goes on, how often, and who does it.
What to watch for, and who to call about it.
The date of the next visit.

Then check your understanding out loud: “I want to be sure I understood. Can I tell you the next steps in my own words?” Ask for written instructions when available and tuck them into the pocket.

After the visit and between visits

Finish each visit page with three short lines: the next appointment, any task assigned to you or your caregiver, and the number to call with questions.

Between visits, add a dated line for each dressing change and anything unusual you notice. Log phone calls too: the date, who you spoke with and what they said. If you want to take photos for the clinician, ask first how the office wants to receive them. The guide to telehealth and wound photos covers the basics.

When instructions change, date the new ones and draw a single line through the old ones so you can still read them. If two members of the care team have told you different things, write both down and ask the treating clinician’s office which one to follow.

What should not wait for the notebook

A notebook is for keeping track, not for holding urgent news until the next visit. Call the treating clinician’s office promptly about spreading redness, fever or chills, new pus or a foul smell, pain that is quickly getting worse, or bleeding that soaks through the dressing. For an emergency, call 911.

If wound follow-up is not arranged yet, you can request care and start the notebook with that first phone call.

Common questions

What if poor eyesight or stiff hands make writing difficult?

Ask whoever is with you to write while you talk. If you are alone, ask the clinician to write or print the key instructions in large letters before leaving. Some people dictate notes into a phone instead of writing, which works just as well.

Should I take my wound care notebook to other medical appointments?

Yes. Your primary care clinician or a specialist may want to know the current dressing plan and how the wound is changing. The notebook also carries news back the other way, such as a new medication or a test result. That two-way sharing is one reason primary care matters for wound healing. Keep old notebooks, too. If a wound returns, your notes on what was tried can save time.

Can I record the visit on my phone instead of taking notes?

Ask the clinician before you start. Many are comfortable with it, but some practices and facilities have their own rules, and a roommate or other people nearby may be picked up on the recording. Even with a recording, write down the three end-of-visit lines.

What is the least I should write when I am worn out?

Three things: today’s date, what changed in the plan, and who to call if there is a problem. That takes a minute and covers most of what you will need later. On a hard day, ask the clinician to write those three lines for you before they go.

General information to help you talk with your own clinician. It is not medical advice, and the treating clinician makes every clinical decision. For a medical emergency, call 911.

Updated October 2026

Keeping a wound care visit notebook.