Why medical records for wound care matter
Good medical records for wound care keep the first visit from being spent on guesswork. A wound has a history: how it started, what has been tried, what tests showed and how its size has changed. A clinician who can read that history can spend the visit examining you.
Records also prevent repeats. A circulation study or a culture done last month may not need to be done again if the result is in hand.
The short list to gather first
If you only have a day or two, focus on these:
- A current medication list, including over-the-counter products and supplements, plus any allergies
- Insurance cards and a photo ID
- The most recent hospital discharge papers or after-visit summary
- Current wound orders or dressing instructions, and the names of the dressings you are using
- Names and phone numbers for your primary care clinician, specialists, home health agency and supply company
See our guides to keeping an up-to-date medication list and preparing for your first wound care visit.
Records about the wound itself
These are the most useful records, and the ones people most often forget to ask for:
- Wound clinic or surgeon notes with dated measurements
- Results of wound cultures or a biopsy, if any were done
- Imaging reports, such as an X-ray or MRI of the area
- Circulation test results, such as an ankle-brachial index or an ultrasound of the leg vessels
- Operative reports, if the wound followed surgery
- Any photos you or a nurse took, with dates
If you have none of this, write your own timeline. Note when the wound appeared, what caused it if you know, which dressings and treatments have been used, and anything that made it better or worse. Half a page is enough.
Records about your overall health
Healing depends on the whole body. Helpful items include recent lab results (especially blood sugar results if you have diabetes), a list of your diagnoses, and notes from a recent hospital or rehabilitation stay.
Bring practical details too, such as the type of mattress, cushion, wheelchair or footwear you use. If someone else makes health decisions for you, bring a copy of the health care power of attorney or guardianship papers. Our guide on who can receive wound care updates explains why that paperwork matters.
How to request your records
You have a legal right to see and get copies of most of your own health records. There are three common routes:
- Patient portal. Many hospitals and offices post visit summaries, lab results and imaging reports online, where you can print or download them.
- Medical records office. Call the hospital or practice and ask for the records department. You will usually sign a request form. Ask how long it takes and whether there is a copying fee.
- Office to office. Sign a release so the new practice can request records directly from the old one.
Be specific. A request for wound clinic notes, measurements and test results from the past several months gets a faster and more useful answer than a request for everything. A full chart can bury the pages that matter.
If you cannot get everything in time
Do not delay a visit because a file is missing. Bring what you have, along with your written timeline. The treating clinician can start from an examination and fill in the rest as records arrive. If the wound is getting worse quickly, with spreading redness or fever, call a clinician now. For an emergency, call 911.
When Gateway arranges a visit, we ask hospitals, clinics and agencies for records with your signed permission, as part of our care coordination work. Tell us where you have been treated and roughly when.
Keeping and sharing records safely
Keep copies in one folder with a one-page summary on top, and bring it to every visit. A wound care visit notebook is a good place to add new instructions as they come.
Please do not type medical details into the form on our website. It is meant for a name and phone number only. Call 314-325-0126 or request care, and we will explain how to get records to the treating practice. If your plan wants paperwork of its own, such as a referral, our insurance page lists questions to ask.
Common questions
How far back should my wound care records go?
For the wound itself, go back to when it started if you can, since early notes show what has already been tried. For general health, the last year of labs and visit notes is usually plenty. Older records matter when they help explain the wound, such as a past vascular procedure, an earlier ulcer in the same spot or radiation to the area.
Can a family member request my records for me?
Yes, with the right permission. Offices will usually release records to another person if you sign an authorization naming them. Someone who legally makes health decisions for you, for example under a health care power of attorney, can generally request them on your behalf and may be asked to show the document.
Should I bring the imaging disc or just the written report?
The written report is the most important piece, because it gives the radiologist’s findings in a form any clinician can read quickly. If you were given a disc or a link to the images, bring that too, since a specialist may want to see the pictures. Do not hold up the visit to track down a disc.
What if my records are at a hospital outside the St. Louis area?
The process is the same. Call that hospital’s medical records office or use its patient portal, and ask for the records to be sent to you or to the treating practice. Requests from out of town can take longer, so start early.
Related pages
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