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Comorbidities
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Dimensions
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# of ulcer
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Location
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Grade
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Pre-measurement
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L__________
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W______
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D_______
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Post-measurement
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L__________
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W______
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D_______
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Type of Ulcer
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Characteristics
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Involvement
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Drainage/Exudate Type
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Odor
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Drainage/Exudate Amount
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Uncovered
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Granulation Tissue
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Wound Edges
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Debridement
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Debridment Type
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Please select level
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Please select instruments
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General Condition of Leg
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Improvement
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Doctor's remarks
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Treatment
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ABx
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Antibiotics
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Labs
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Culture
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Bone Scan / MRI
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X - ray
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Office Wound Care Techniques
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Ancillary Services
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Dressing Type/Supplies
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Wound Healing Techniques
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Assessment
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Assessment
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Plan
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Follow Up
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Plan
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Doctor's remarks
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