Wound assessment
to be completed at initial assessment then once weekly thereafter
Initial assessment or weekly review
Initial
weekly review
Date of Assessment
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Patient First Name
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Patient Last Name
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patient date of birth
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Patient address
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name of person completing this form
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Shift Start time
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Shift end time
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image of wound (if appropiate)
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date wound appeared
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location of wound
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Thickness of wound
Skin tear class
aetiology
surgical
arterial
venous
pressure
diabetic
other
Stage (PI)
I
II
III
IV
which of the following Diagnostic Tests have been performed to confirm aetiology
ABPI
Biopsy
Other
What date was the ABPI?
Result of the ABPI
What was the date of the Biopsy
Result of the Biopsy
What other diagnostic test was conducted?
what was the date of the other diagnostic test
result of other diagnostic test
pain level
1
2
3
4
5
6
7
8
9
10
pain type
Pain location
Pain pattern
known allergies?
medications affecting healing
Corticosteroids
Anti-coagulant
NSAID’s
Cardiovascular
Antibiotics
Topical treatments
other
What 'other' medications are affecting healing
medical history
Diabetes mellitus
Cardiac Disease
Respiratory Disease
Malignancy
Chemo/radiotherapy
Blood Disorder (eg anaemia)
Neurological/Muscular skeletal
Peripheral Vascular Disease
Renal Failure
Incontinence
Nutrition Deficit
Poor Hydration
Other
Diabetes mellitus type
Diabetes mellitus level
Diabetes mellitus Last HBA1C
Define 'other' for medical history
Goals
Control pain
prevent infection
Control Underlying Factors
other
define 'other' goals
Comments
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