As in any other patient encounter, documentation is critical. For wounds, a brief history with attention to mechanism of injury should be included. Physical examination should be specific about size and location of the injury, and should include neuro-vascular and tendon function. Your findings during exploration of the wound should also be documented. You should also include any discussions you had regarding foreign bodies, risk of infection, etc.
Discharge instructions are critical.
Instructions should explain signs of infection and other potential complications, and provide information on appropriate follow-up for wound checks if necessary and suture removal. If the doctor said to use a bandage, keep the bandage clean and dry. Change wet bandages immediately. Do not soak the wound. Pat the area dry.