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Progress Notes
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Wound location
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Classification
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Status
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Stage
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Pre-Debridement Length
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Pre-Debridement Width
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Pre-Debridement Depth
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Pre-Debridement Area
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WOUND EVALUATION
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Exudate amount
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Exudate Type
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Wound Bed Tissue
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Epithelialization
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Wound edges
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Wound size
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Wound bed
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Undermining
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Tunneling
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Exposed structures
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Periwound color
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Wound duration
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Odor
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Infection
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Clinical Signs of Infection
• • •
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Conservative Treatment
• • •
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Vascular Status
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Pulses
• • •
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Neurology
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Digital Hair
• • •
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Skin Temperature
• • •
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Pin Prick
• • •
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Soft Touch
• • •
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Monofilament Testing
• • •
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DEBRIDEMENT
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Debridement Type
• • •
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Instrument Used
• • •
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Anesthesia Used
• • •
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Post-Debridement Length
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Post-Debridement Width
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Post-Debridement Depth
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Post-Debridement Area
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Procedure
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Patient Education
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Treatment Orders/Notes
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CTP APPLICATION
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Tobacco
• • •
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Past Surgical History:
• • •
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Living Arrangements
• • •
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Caregiver/Home Health Agency
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Current Services
• • •
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Hospitalization History:
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