|
Wound Number
• • •
|
Photo
|
|
Location
|
Etiology
• • •
|
|
Depth of Tissue Injury
• • •
|
Stage of Pressure Ulcer/Thickness
• • •
|
|
Length
|
Width
|
|
Depth
|
Undermining (by clock) Dept (cm)
|
|
Tunneling (by clock) Dept (cm)
|
Eschar
• • •
|
|
Granulation
• • •
|
Slough
• • •
|
|
Periwound
• • •
|
Wound Edges
• • •
|
|
Drainage Amount
• • •
|
Drainage Color
• • •
|
|
Tendon/Muscle/Bone Exposed
• • •
|
Odor Present
• • •
|
|
Pain related to wound
• • •
|
Pulses Present
• • •
|
|
Extremity Edema Present
• • •
|
Cap Refill
• • •
|
|
Use for Debridement Documentation
|
Type of Debridement
• • •
|
|
Selective/Nonselective
• • •
|
Pre Debridement Wound Measurement: L X W X D
|
|
PRE-Debridement Wound Square Surface Area:
|
Post Debridement Photo
|
|
Reason for Sharp Debridement
• • •
|
Debridement Instrument Used:
• • •
|
|
Depth of Tissue Debrided to:
• • •
|
Anesthesia used:
|
|
Blood loss during procedure
• • •
|
Procedure Summary
|
|
WOUND DRESSING: Cleanser
|
Peri-wound application
|
|
Undermining/Tunneling Dressing
|
Topical
• • •
|
|
Primary Dressing
• • •
|
Secured With
|
|
Comments
|
Pressure Reduction Devices/Offloading Devices
• • •
|
|
Positioning Devices
• • •
|
Cushions and Seating Supports
• • •
|
|
Wound 2
|
|
|
Wound Number
• • •
|
Photo
|
|
Location
|
Etiology
• • •
|
|
Depth of Tissue Injury
• • •
|
Stage of Pressure Ulcer/Thickness
• • •
|
|
Length
|
Width
|
|
Depth
|
Undermining (by clock) Dept (cm)
|
|
Tunneling (by clock) Dept (cm)
|
Eschar
• • •
|
|
Granulation
• • •
|
Slough
• • •
|
|
Periwound
• • •
|
Wound Edges
• • •
|
|
Drainage Amount
• • •
|
Drainage Color
• • •
|
|
Tendon/Muscle/Bone Exposed
• • •
|
Odor Present
• • •
|
|
Pain related to wound
• • •
|
Pulses Present
• • •
|
|
Extremity Edema Present
• • •
|
Cap Refill
• • •
|
|
Use for Debridement Documentation
|
Type of Debridement
• • •
|
|
Selective/Nonselective
• • •
|
Pre Debridement Wound Measurement: L X W X D
|
|
PRE-Debridement Wound Square Surface Area:
|
Post Debridement Photo
|
|
Reason for Sharp Debridement
• • •
|
Debridement Instrument Used:
• • •
|
|
Depth of Tissue Debrided to:
• • •
|
Anesthesia used:
|
|
Blood loss during procedure
• • •
|
Procedure Summary
|
|
WOUND DRESSING: Cleanser
|
Peri-wound application
|
|
Undermining/Tunneling Dressing
|
Topical
• • •
|
|
Primary Dressing
• • •
|
Secured With
|
|
Comments
|
Pressure Reduction Devices/Offloading Devices
• • •
|
|
Positioning Devices
• • •
|
Cushions and Seating Supports
• • •
|
|
Wound 3
|
|
|
Wound Number
• • •
|
Photo
|
|
Location
|
Etiology
• • •
|
|
Depth of Tissue Injury
• • •
|
Stage of Pressure Ulcer/Thickness
• • •
|
|
Length
|
Width
|
|
Depth
|
Undermining (by clock) Dept (cm)
|
|
Tunneling (by clock) Dept (cm)
|
Eschar
• • •
|
|
Granulation
• • •
|
Slough
• • •
|
|
Periwound
• • •
|
Wound Edges
• • •
|
|
Drainage Amount
• • •
|
Drainage Color
• • •
|
|
Tendon/Muscle/Bone Exposed
• • •
|
Odor Present
• • •
|
|
Pain related to wound
• • •
|
Pulses Present
• • •
|
|
Extremity Edema Present
• • •
|
Cap Refill
• • •
|
|
Use for Debridement Documentation
|
Type of Debridement
• • •
|
|
Selective/Nonselective
• • •
|
Pre Debridement Wound Measurement: L X W X D
|
|
PRE-Debridement Wound Square Surface Area:
|
Post Debridement Photo
|
|
Reason for Sharp Debridement
• • •
|
Debridement Instrument Used:
• • •
|
|
Depth of Tissue Debrided to:
• • •
|
Anesthesia used:
|
|
Blood loss during procedure
• • •
|
Procedure Summary
|
|
WOUND DRESSING: Cleanser
|
Peri-wound application
|
|
Undermining/Tunneling Dressing
|
Topical
• • •
|
|
Primary Dressing
• • •
|
Secured With
|
|
Comments
|
Pressure Reduction Devices/Offloading Devices
• • •
|
|
Positioning Devices
• • •
|
Cushions and Seating Supports
• • •
|
|
Wound 4
|
Wound Number
• • •
|
|
Photo
|
Location
|
|
Etiology
• • •
|
Depth of Tissue Injury
• • •
|
|
Stage of Pressure Ulcer/Thickness
• • •
|
Length
|
|
Width
|
Depth
|
|
Undermining (by clock) Dept (cm)
|
Tunneling (by clock) Dept (cm)
|
|
Eschar
• • •
|
Granulation
• • •
|
|
Slough
• • •
|
Periwound
• • •
|
|
Wound Edges
• • •
|
Drainage Amount
• • •
|
|
Drainage Color
• • •
|
Tendon/Muscle/Bone Exposed
• • •
|
|
Odor Present
• • •
|
Pain related to wound
• • •
|
|
Pulses Present
• • •
|
Extremity Edema Present
• • •
|
|
Cap Refill
• • •
|
Use for Debridement Documentation
|
|
Type of Debridement
• • •
|
Selective/Nonselective
• • •
|
|
Pre Debridement Wound Measurement: L X W X D
|
PRE-Debridement Wound Square Surface Area:
|
|
Post Debridement Photo
|
Reason for Sharp Debridement
• • •
|
|
Debridement Instrument Used:
• • •
|
Depth of Tissue Debrided to:
• • •
|
|
Anesthesia used:
|
Blood loss during procedure
• • •
|
|
Procedure Summary
|
WOUND DRESSING: Cleanser
|
|
Peri-wound application
|
Undermining/Tunneling Dressing
|
|
Topical
• • •
|
Primary Dressing
• • •
|
|
Secured With
|
Comments
|
|
Pressure Reduction Devices/Offloading Devices
• • •
|
Positioning Devices
• • •
|
|
Cushions and Seating Supports
• • •
|
|
