Sterile Dressing Change Documentation: 5-Step Nursing Charting Guide

Step-by-Step Charting

1. Assessment

• Wound/periwound: infection signs (redness, swelling, drainage, pain)
• Size, location, drainage characteristics
• Pain level, other symptoms

2. Preparation

• Supplies: sterile gloves, dressings, antiseptic, saline
• Hand hygiene, sterile gloving
• Cleanse wound/periwound with antiseptic/saline

3. Dressing Change

• Remove old dressing carefully
• Apply new sterile dressing
• Secure with tape/bandage

4. Documentation

• Date/time
• Procedure details (dressing type)
• Assessment findings (infection signs, changes)
• Patient response (pain relief, tolerance)

5. Follow-Up

• Schedule next assessment/change
• Home care instructions

Key Principles

• Standard precautions always
• Sterile technique for infected wounds
• No bare-hand wound contact
• Thorough, accurate charting in medical record