A wound care visit rarely happens at a desk. You are at a bedside, in a clinic hallway, or in a patient's room, and the chart still has to be complete, defensible, and signed. This guide lays out a point of care workflow for wound care charting, built around one principle: gather everything first, then generate the documentation in a single pass.
Why capture before you generate
Most charting delays come from doing documentation in pieces: a note here, an order there, a missing diagnosis found at the end of the day. A better pattern is to treat the encounter as one workspace with several areas to prepare. Nothing is submitted until you choose to generate, so you can move between areas freely as the visit unfolds.
The workflow described here follows an encounter in the WoundScribe platform, which has a progress tracker and eight tabs for the visit.
The bedside checklist
Work through these areas before you generate notes:
- Clinical note. Start with the Smart Clinical Overview, which summarizes the patient's course, treatment, and active wounds. Then dictate or type your encounter note. Dictation suits bedside work, and the more context you give, the better the generated notes will be.
- Intake. Record vitals, attachments, and the intake checklist for this visit. Anything left incomplete is flagged in a pre-flight check later.
- Wounds. Select the wounds this encounter covers. If you find a new wound, add it by typing a short description; the type and location are parsed for you.
- Orders and Rx. Place labs, imaging, referrals, procedures, DME, and e-prescriptions while the findings are fresh.
- Labs, imaging, referrals, and media. These share one strip with live counts, so you can see what is attached to the encounter at a glance.
Why every order needs a diagnosis
Payers require a diagnosis on each order, so each order must carry at least one linked ICD-10 diagnosis. Linking it at the time you place the order is faster than reconstructing the reasoning later. For diabetic foot ulcer visits especially, this keeps orders for offloading equipment, imaging, or referrals tied to the condition that justifies them.
One button, then a pre-flight check
When the tabs are ready, select Generate Notes at the bottom of the page. If something important is missing, a pre-flight dialog lists it. You can go back and fix the flagged items, or generate anyway if you have a reason to proceed.
The encounter then moves into Generating, and AI agents run in sequence: summarizer, assessment, planner, and validator. The pass usually finishes in under a minute, and you do not have to stay on that screen. You can move on to the next patient while it runs.
Review is where clinical judgment lives
Generated documentation is a draft, and the review step is yours. After generation, check three outputs:
- The drafted SOAP note.
- The procedures note.
- The patient summary.
The system also recommends orders. Accept the ones you agree with in the Orders and Rx tab, then approve and sign. That closes the loop: capture the visit, generate the notes, review the recommended orders, and sign off.
Where this fits in a wider workflow
If you want to see how the documentation side connects to the rest of the platform, the wound documentation system page explains the broader approach. For the exact tab-by-tab steps, the original post, Running an Encounter, walks through them in order.
Practical habits that save time
- Dictate the encounter note while you examine the wound, not afterward.
- Select wounds early so the tab count reflects the visit.
- Place orders before generating so the planner has them to work from.
- Treat the pre-flight dialog as a final checklist, not an obstacle.
Documenting at the point of care is mostly about sequence. Prepare each area, press one button, review carefully, and sign.