The Simple Guide to Write SOAP Notes for Wound Care

Writing SOAP Notes for Wound Care

Let me guess: you know wound care inside and out, but when it comes to writing it up in your SOAP notes, you find yourself staring at that blank screen wondering where to start? You're definitely not alone.

After years of working with healthcare providers and building tools to make documentation easier, I've noticed that wound care SOAP notes seem to trip up even the most experienced clinicians.

There's just so much to observe, measure, and communicate, and getting it all down in a clear, comprehensive way can feel overwhelming.

A jiffy into SOAP Notes

Before we dive into the specifics of wound care documentation, let's take a step back and talk about SOAP notes themselves.

If you've been in healthcare for any length of time, you've probably written thousands of them. But have you ever stopped to think about where they came from?

SOAP notes were actually developed back in the 1960s by Dr. Lawrence Weed at the University of Vermont.

Dr. Weed was frustrated with the scattered, inconsistent way medical information was being recorded, so he created this structured approach to bring some order to the chaos.

The acronym stands for Subjective, Objective, Assessment, and Plan.

Here's what makes SOAP notes so brilliant: they force us to think systematically.

The Subjective section captures what the patient tells us.

Objective covers what we observe and measure.

Assessment is where we put our clinical thinking on paper.

And Plan outlines what we're going to do about it. It's logical, it's comprehensive, and it creates a clear trail that any healthcare provider can follow.

In wound care specifically, this structure becomes your best friend because wounds are so visual and detail-oriented.

You need a systematic way to capture everything from the patient's pain level to the exact measurements of the wound bed—and SOAP notes give you that framework.

The Right Approach to SOAP Notes for Wound Care

SOAP notes give structure to your wound care documentation. But the real challenge is knowing what exactly goes into each section, especially when you’re trying to capture wound details that may change from day to day.

Below is a step-by-step breakdown of each component of a SOAP note, with a wound-care lens.

S – Subjective

This section is about the patient’s perspective. Document what they tell you, their symptoms, concerns, or feelings about the wound.

Things to include:

Pain level: Ask the patient to rate their pain on a 0–10 scale.
Pain description: Burning, throbbing, sharp, dull?
Patient concerns: “It smells bad,” “It feels worse today,” or “I can’t put weight on it.”
Functional impact: Any limitation in mobility, dressing, or daily activities.

✅ Example (Subjective):

Patient reports wound pain at 6/10, describing it as throbbing and constant. States that the odor has worsened since yesterday and is having difficulty bearing weight on the affected leg.

O – Objective

This is your clinical observation and measurable data. This section should be the most detailed in wound care.

Key elements to document:

Wound location (e.g., right heel, sacral area, left calf).
Wound bed characteristics: color, granulation tissue, slough, eschar.
Drainage: type (serous, serosanguinous, purulent), amount (scant, moderate, copious), odor.
Wound edges/margins: well-defined, irregular, macerated.
Periwound skin: intact, erythematous, indurated.
Measurements:
- Length: head-to-toe orientation.
- Width: side-to-side.
- Depth: measured with sterile applicator.
- Tunneling/undermining: location and measurement if present.
Dressing status: intact, soiled, saturated, displaced.
Vital signs (if relevant): fever, tachycardia, or other infection indicators.

✅ Example (Objective):

Wound located on left lower leg, mid-shin. Dimensions: 3.2 cm length × 2.0 cm width × 0.7 cm depth. Wound bed red with granulation tissue, scattered yellow slough. Moderate serosanguinous drainage present, no foul odor. Edges well-defined, periwound skin slightly erythematous but intact. No tunneling or undermining noted. Dressing removed intact.

Quick tip: What I like to do with wound care is to head over soapnotes.doctor/room at the start of a new session. Record the patient's discussion about what they feel about the wound (the subjective) while the session begins. End the session. Observe the clinical details for the session and use the tailorr feature to add them. Review and copy and paste to your EHR!

A – Assessment

Here, you provide your clinical judgment about the wound’s current status and healing trajectory. This is where your expertise comes in.

Consider:

Is the wound improving, stable, or worsening?
Are there signs of infection?
Is granulation tissue forming as expected?
How does this wound compare to the last documented note?

✅ Example (Assessment):

Wound shows evidence of healing with granulation tissue formation. Presence of minor slough but no clinical signs of infection. Periwound erythema likely related to dressing friction rather than cellulitis.

P – Plan

This is the next step.

Your treatment and care strategy. Be clear and actionable.

Things to include:

Dressing change (type, frequency).
Cleansing solution (e.g., saline, antiseptic).
Adjunctive therapies (e.g., debridement, negative pressure wound therapy).
Patient/caregiver education.
Follow-up schedule.
Referrals if needed (e.g., wound care specialist, infectious disease).

✅ Example (Plan):

Cleanse wound with sterile saline. Apply hydrocolloid dressing and change every 48 hours. Educate patient on offloading strategies to reduce pressure. Monitor for signs of infection and reassess in 72 hours. Will consider surgical debridement if slough does not decrease by next visit.

Putting It All Together – Example SOAP Note for Wound Care

S: Patient reports pain 6/10, throbbing, worse with ambulation. Notes increased odor.

O: Wound on left shin. Measures 3.2 × 2.0 × 0.7 cm. Red granulation tissue with scattered yellow slough. Moderate serosanguinous drainage, no odor at time of exam. Edges well-defined. Periwound erythematous but intact. Dressing intact on removal. No tunneling.

A: Wound improving overall with granulation tissue. Mild slough present. No evidence of infection.

P: Cleanse with sterile saline. Hydrocolloid dressing every 48 hrs. Patient education on offloading. Reassess in 72 hrs. Monitor for infection.

From 2 Hours to 2 Minutes. Quit Manual Note Taking.