Skip to main content
Beta version A NHS service powered by standards. Feedback opens in a new window will help us improve.

Wound Care Information Standard

Gives a framework for clinicians to record the clinical assessment, observations and treatments given.

Contents

Documentation
View documentation for this standard

About this standard

Publisher
NHS England
Reference code
DAPB4086 Amd 60/2022
Publication date
10 November 2023
Status
Active
Show definitions of statuses

Active. Active standards are stable, maintained and have been approved, assured or endorsed for use by qualified bodies.

Deprecated Deprecated standards are available for use and are maintained, but are being phased out, so new functionality will not be added.

Retired standards Retired standards are not being maintained or supported and should not be used.

Standard type
  • Information standards
  • Technical standards and specifications
Show definitions of standard types

Collections. A Collection is a systematic gathering of a specified selection of data or information for a particular stated purpose from existing records held within health and care systems and electronic devices.

Extractions. An extraction is a type of collection that is pulled from an operational system by the data controller and transmitted to the receiver without additional processing or transcription by the sender.

Information standards. Information standards are agreed ways of doing something, written down as a set of precise criteria so they can be used as rules, guidelines, or definitions.

Technical Standards and specifications. Technical standards and specifications specify how to make information available technically including how the data is structured and transported.

Contact point

england.standards.assurance@nhs.net

Using this standard

The Professional Record Standards Body (PRSB) were commissioned by NHS England to develop the following set of resources. These have been migrated into the NHS Standards Directory and will be managed by NHS England from 01 January 2026.

Associated medias
Applies to
  • Primary care services providing wound care MUST comply
  • Community services providing wound care MUST comply
  • Secondary care services providing wound care MUST comply
  • Mental health services providing wound care MUST comply
  • Social care services providing wound care SHOULD comply
  • Ambulance services providing wound care SHOULD comply
Impacts on
Implementation of this information standard impacts all health IT systems suppliers providing systems to the above providers; suppliers should work with their customers to determine necessary changes.
Effective from
1 November 2023

Topics and care settings

Topic
  • Care records
  • Key care information
Care setting
  • Community health
  • GP / Primary care
  • Hospital
  • Maternity
  • Mental health
  • Social care
  • Urgent and Emergency Care

Dependencies and related standards

Dependencies

Review Information

Scope
Health Services, NHS Services, Adult Social Care
Sponsor

Margaret Kitching, Chief Nurse NHS England - NE & Yorkshire (NWCSP Executive Sponsor), NHS England

Senior Responsible Officer

Una Adderley, Programme Director, National Wound Care Strategy programme

Business Lead
Martin Orton, Senior Programme Manager, Professional Record Standards Body (PRSB)
Contributor
Professional Record Standards Body (PRSB)
Approval date
27 July 2023
Post Implementation review Date
31 July 2026
Technical Committee

Data Alliance Partnership Board (DAPB)

Legal basis

Link to Information Standards Notice (ISN)
View the information standards notice

Information Standards Notices (ISNs) are published to announce new or changes to information standards published under section 250 of the Health and Social Care Act 2012

Legal authority

Section 250 of the Health and Social Care Act 2012 This information standard is published under section 250 of the Health and Social Care Act 2012.

Licence information

NHS England permits the copying and re-use of Information Standards, in whole or in part, for commercial and non-commercial purposes but, to protect the integrity of the Information Standards, you are not permitted to adapt, amend or decompile the Information Standards for any purpose without our prior consent.

Licence

Crown Copyright https://digital.nhs.uk/about-nhs-digital/terms-and-conditions

More information

The standard is intended to support the aims of the National Wound Care Strategy Programme (NWCSP) to:

  • Reduce patient suffering
  • Improve healing rates
  • Prevent wounds occurring and recurring
  • Use clinical time and other health and care resources in the most effective way
It is based on professional guidance, the relevant NICE guideline, evidence review, and extensive consultation with health professionals, people, and carers. Scope The standard covers the assessment, diagnosis, treatment, ongoing care and prevention of the wounds across all health and care settings for three areas of wound care;
  • Lower limb (leg and foot) wounds
  • Pressure ulcers
  • Surgical wound complications
  • The standard is UK wide and is for adults and children.
Out of scope:
  • Wound types not specified above, including those caused by external factors such as new trauma and burns (although it may work for these).
  • Management of arterial and peripheral vascular disease. While leg wounds often result from peripheral venous or arterial disease, prevention and management of vascular disease is beyond the scope of this standard.
  • Management of Lymphoedema. While leg wounds may result from lower limb lymphoedema, management of lymphoedema is beyond the scope of this standard.
How it works With the exception of surgical wounds, wound care normally starts with a baseline assessment of the wound and the person. The wound assessment and treatment section of this standard allows for recording details of the “contact with professionals” for each contact. This is likely to be followed by a “baseline assessment”, “clinical observations”, and initial treatments. The baseline assessment is then likely to be used to develop a treatment plan through discussion with the individual of their “About Me” information, gathering their “Person preferences” and considering the relevant treatments. The treatment plan would be added to their “personalised care and support plan” using the “care and support plan” section for their needs, goals and actions and if needed an “additional support plan” for the details of the medical treatment. A “contingency plan” (also known as an escalation plan) can also be created if appropriate. It is recognised that for surgical wounds, the treatment plan may be developed pre-surgery, and the assessment and treatment will only apply if wound complications occur post-surgery. All further contacts with professionals would then be recorded in a similar way along with assessments, observations and treatments as deemed professionally appropriate. The standard supports professional guidance by allowing consistent information to be recorded with the potential for prompts for the information recorded in assessments, observations and treatments. The supported self-care (self-management) section enables the recording of any self-care that the person with a wound may do, and for the person to record documents or images which can be uploaded to a clinical system or patient record. Mandatory, required and optional All elements in the information standard are defined as either Mandatory, Required or Optional. Very few elements are mandatory, many are required and these only need to be entered when they are collected or known, and can be left blank when they are not appropriate for that occasion.
  • Mandatory – The information must be recorded.
  • Required – If it exists, the information must be recorded.
  • Optional – Local decision is made as to whether the information is recorded.
Implementing the standard The information standard defines the data that should be recorded to support care professionals in their delivery of high quality care. IT system suppliers are expected to build or customise their clinical systems to allow the recording of this data. Systems will be a mix of specialist wound care management systems and more general electronic patient record systems. Care professionals need to be aware of the standard but do not need to have a complete, in depth understanding of the detail of the standard’s information model. Care professionals should be reassured that their system has implemented and operates in accordance with the information standard. It is recommended that those responsible for clinical systems check if their suppliers have implemented the standard.

Page last updated: 30 March 2026