|
Date:
|
|
|
Annual US follow up
|
|
|
Initial US follow up
|
|
|
Compression Stocking F/U
|
|
|
Compression stocking compliance
|
|
|
Compression stocking wear
|
|
|
Compression start date (consult)
|
|
|
Pt complaints
• • •
|
|
|
ADL's affected
• • •
|
|
|
Meds/allergies
|
|
|
Vitals
|
|
|
P.E.: RLE
• • •
|
|
|
P.E. LLE
• • •
|
|
|
Further comments
|
|
|
CEAP-clinical
• • •
|
|
|
CEAP-etiology
• • •
|
|
|
CEAP- anatomic
• • •
|
|
|
CEAP pathophysiologic score
• • •
|
|
|
Venous clinical severity score
• • •
|
|
|
Assessment
• • •
|
|
|
Chronic ulceration location code
• • •
|
|
|
Pressure ulcer (s) stages:
• • •
|
|
|
Further comments
|
|
|
Plan
• • •
|
|
|
Comments
|
|
|
Time spent
• • •
|
|
|
Nurse/midlevel/PROVIDER:
• • •
|
|
|
Data compiled by
• • •
|
|
