|
WOUND #
|
TYPE
|
|
STAGE/GRADE
|
LOCATION
|
|
PROGRESS
• • •
|
PROGRESS
|
|
|
Signs of Response To Treatment
• • •
|
|
Previous Conventional Treatment Failed
• • •
|
|
|
|
Underlying disease process contributing to failure of closure discussed in baseline visit.
• • •
|
|
Chronic Wound Status
• • •
|
|
|
Wound Site Previously Grafted with Amnio Graft (Initial Assesment Only)
|
Wagner Classification System: For Diabetic Foot Ulcer (DFU's)
|
|
Full Thickness Ulcer
• • •
|
Duration of the ulcer: Specify # of days, weeks, months, years.
|
|
Consent Form Discussed & Signed (initial visit)
|
Frequency of Amnio Graft application.
|
|
|
|
|
ODOR
|
COLOR
• • •
|
|
NONVIABLE
|
SLOUGH
|
|
ESCHAR
|
OTHER
|
|
DRAIN QUANT
|
DRAIN QUALITY
|
|
INFECTION
• • •
|
EXPOSED
• • •
|
|
PERIWOUND
• • •
|
|
|
|
|
|
LENGTH
|
WIDTH
|
|
DEPTH
|
UNDERMINING
|
|
|
|
|
PROCEDURE
|
|
|
POST-OP DX SAME
|
OTHER POST-OP DX
|
|
INSTRUMENTS
• • •
|
ANALGESIA
• • •
|
|
POSTOP NONVIABLE
|
TISSUES
• • •
|
|
BLEEDING
|
HEMOSTASIS
|
|
TOLERANCE
|
|
|
|
|
|
DRESSING
• • •
|
Treatment Applied During Visit:
|
|
SERIAL
|
MARGINS CHANGED
|
|
POST LENGTH
|
POST WIDTH
|
|
POST DEPTH
|
AREA
|
