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Visit information
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Arrival condition
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Mentation status
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Notes/Comments
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Ambulatory status
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Notes/Comments
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Medical history
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Any changes to medical history?
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Changes to medical history
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Any new surgeries or procedures?
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New surgeries or procedures (and dates)
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Assessment
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Cardiovascular
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If abnormal,
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Respiratory
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If abnormal,
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GI
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If abnormal,
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Pulses
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Leg pulses
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Arm pulses
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Popliteal
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If Abnormal, please specify
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Posterior Tibial
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If Abnormal, please specify
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Dorsal Pedis
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If Abnormal, please specify
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Radial pulse
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If Abnormal, please specify
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Brachial pulse
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If Abnormal, please specify
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Color
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Notes/Comments
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Sensation
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Hair growth
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Temperature
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Capillary refill
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Erythema
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Dependent rubor
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Hyperpigmentation
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Hemosiderin staining
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Active Wound
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If yes,
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Treatment progress
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What type of compression is patient currently wearing at this stage in treatment?
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Is patient tolerating compression?
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Skin assessment
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Comments
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Diagram
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Photo
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Swelling
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Pitting
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Stemmer's
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Lymphedema location
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Lymphedema stage
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Pain
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Pain characteristics
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Does the swelling reduce with elevation?
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Comments
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Problems
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Difficulties with any of the following?
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Loss of function, strength, or mobility?
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Contraindications
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Notes/Comments
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Pt. presents w/ limited or no knowledge of lymphedema tx and/or lymphedema precautions
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Pt. presents w/ limited or no knowledge of skin care and infection prevention
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Pitting edema w/ increased risk of infection
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No HEP
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No compression bandaging skills
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Pt. has no / inadequate compression garment to control lymphedema
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Goal progress
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What treatments were completed during this session?
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Other:
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Time spent performing MLD
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Comments
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If multi-layer short stretch bandaging was applied, specify location
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Comments
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Response to treatment
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If Poor, please specify
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Plan for next visit
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TREATMENT PLAN
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Education
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Educated on:
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How much time was spent educating the patient?
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Plan / Follow-up
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Other
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Discharge from care
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If NO
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Follow-up date
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Patient is progressing well towards goals as evidenced by
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Sensation intact after compression applied
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Capillary refill after compression
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Completed by:
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