Wound Care Assessment Documentation Guide

Accurate wound assessment and documentation is a critical clinical skill in aged care — directly affecting resident outcomes and compliance with Standard 5 of the Strengthened Quality Standards. This guide provides aged care staff with a systematic approach to wound classification, assessment, care planning and progress documentation.

Published

May 29, 2026

Wound Care Assessment and Documentation Guide for Aged Care

Effective wound care in aged care requires accurate assessment, evidence-based treatment and meticulous documentation. Whether managing pressure injuries, leg ulcers, diabetic wounds or surgical sites, aged care staff must follow a systematic process that ensures wounds are identified early, treated appropriately and tracked over time. This guide supports clinical teams to meet their wound care obligations under Standard 5 of the Strengthened Aged Care Quality Standards.

What This Guide Covers

Wound classification — acute, chronic, pressure injuries and moisture-associated skin damage
Pressure injury staging (Stage 1–4, unstageable, deep tissue injury)
Wound assessment frameworks — TIME (Tissue, Infection, Moisture, Edges)
Infection indicators and when to escalate to a GP or wound consultant
Wound care product selection — dressings, debridement and moisture management
Completing a wound assessment and progress note accurately
Wound photography — when and how to document with images
Prevention strategies — skin checks, repositioning, nutrition and hydration

Key Learning Outcomes

Classify and stage common wound types encountered in aged care
Complete a structured wound assessment using the TIME framework
Recognise clinical indicators of wound infection and escalate appropriately
Accurately document wound assessment findings and treatment in the care record
Implement and document evidence-based wound prevention strategies

Who Should Complete This Training

RNs and enrolled nurses are primarily responsible for wound assessment and care planning. PCAs should complete wound care awareness training to support prevention, recognise changes and report concerns. Wound care specialists (CNCs) or GP-led review should be accessible for complex wounds.

Alignment to the Strengthened Aged Care Quality Standards

Directly relevant to Standard 5 (Clinical Care), which mandates systematic, evidence-based clinical care including the prevention and management of pressure injuries, and Standard 4 (Care and Support), requiring care plans to address identified clinical needs including wound management goals.

Keep Wound Care Records Audit-Ready with Governa

Governa helps clinical teams maintain up-to-date wound care records linked to your facility's wound management policy — and surfaced on demand by Norma. No more searching through ring binders at audit time.

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