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FREE TEXT
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Please use the ‘Clinical Photos’ form under additional
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GEN
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GEN
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HEENT
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HEENT
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NECK
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NECK
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CHEST
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CHEST
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CARDIOVASCULAR
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CARDIOVASCULAR
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ABD
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ABD
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NEURO
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NEURO
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UPPER EXTREMITIES EXAMINATION
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UPPER EXTREMITY
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Upper extremity note
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Left Radial Artery
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Left Ulnar Artery
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Right Radial Artery
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Right Ulnar Artery
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Upper Extremity Vascular Anatomy (reference)
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AAA recommendations reference
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Dialysis Access
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ACCESS
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Common Fistula sites (reference)
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Abnormal Phys exam findings
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Phys Exam findings [other]
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LOWER EXTREMITIES EXAMINATION
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Spider/Reticular Veins
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Palpable Varicose/Visible Varices
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Refractory Dependent Edema
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Erythema
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Bleeding Veins
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Hyperpigmentation
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Venous Eczema
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Lipodermatosclerosis
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Atrophie Blanche
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Corona Phlebectasia
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Scars from Trophic Ulcers
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Hair Loss
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Active Ulcers
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Active Ulcer description
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Healed Ulcers
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Healed Ulcer description
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OTHER description
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RIGHT lower extremity
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Evaluation for PAD limited by
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FEMORAL
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POPLITEAL
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POSTERIOR TIBIAL
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DORSALIS PEDIS
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CAPILLARY REFILL TIME
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description
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LEFT lower extremity
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Evaluation for PAD limited by
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FEMORAL
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POPLITEAL
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POSTERIOR TIBIAL
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DORSALIS PEDIS
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CAPILLARY REFILL TIME
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description
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TUBES & LINES - FOCUSED EXAM
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CENTRAL line(s) (Indicate L/R and type)
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size ___ French
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Date last exchanged/placed
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description
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Tube Type 1
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Tube - other
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Granulation Tissue Surrounding Ostomy?
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Tube integrity and surrounding skin
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Date last exchanged/placed
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TUBES & LINES...MORE
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Tube Type 2
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Tube - other
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Granulation Tissue Surrounding Ostomy?
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Tube integrity and surrounding skin
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Date last exchanged/placed
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Does the patient have an active or healed Lower Extremity wound?
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If yes, turn on
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Is the wound Active (yes) Healed (no)?
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Photo Documentation Location
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Is this wound being actively managed by wound care?
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