BSN Tracker

Assessment Tool: Surgical Incision Assessment

Structured documentation of surgical wound status. Complete at every dressing change, record post-op day, and compare findings to baseline. Report signs of surgical site infection (SSI) to the surgeon promptly.

Surgical Incision Assessment

Comprehensive nursing wound assessment for surgical incisions. Complete at every dressing change. Document post-op day, compare to baseline, and report changes to the surgeon promptly.

Patient & Procedure Context
Wound Edges

Select the best description of wound edge status

Tissue Type

Select predominant tissue type visible in the wound bed

Exudate (Drainage)

Describe drainage type, if present

Periwound Skin

Assess skin within ~10 cm of wound margins

Odor

Assess after removing dressing; before cleansing

Pain at Incision Site

Patient-reported pain using NRS (0 = no pain, 10 = worst imaginable)

0
0 – None 5 – Moderate 10 – Severe
Signs of Infection — SIADIE Checklist

Check all signs present. Any positive finding warrants provider notification and documentation per CDC SSI criteria.