|
Comorbidities
• • •
|
|
|
Dimensions
|
|
|
# of ulcer
|
Location
|
|
Grade
|
|
|
Pre-measurement
|
|
|
L__________
|
W______
|
|
D_______
|
|
|
Post-measurement
|
|
|
L__________
|
W______
|
|
D_______
|
|
|
Type of Ulcer
• • •
|
|
|
Characteristics
• • •
|
Involvement
• • •
|
|
Drainage / Exudate
• • •
|
Odor
• • •
|
|
Granulation Tissue
• • •
|
uncovered
• • •
|
|
Edges Skin
• • •
|
|
|
Debridement
|
|
|
If yes, please select.
• • •
|
Please select
• • •
|
|
Improvement
|
General Condition of Leg
• • •
|
|
Treatment
|
|
|
Antibiotics
• • •
|
ABx
|
|
Culture
• • •
|
Labs
• • •
|
|
X - ray
|
Bone Scan / MRI
|
|
Wound Healing Techniques
• • •
|
Doctor's remarks
|
|
Assessment
• • •
|
Plan
• • •
|
|
Assessment
|
Plan
|
