Wound dressing change assessment form

to be completed at every dressing change

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Address *

Full name of person completing form *

date of completing form *

Shift start time *

Shift end time *

Wound Number *

location of wound on the body *

Wound measurements (mm)

max would length

max wound width

max wound depth

tracing fortnightly

undermining presentation

yesno

located at (.. o'clock)

mm deep

cleansing solution

topical treatment

primary dressing

secondary dressing

other

Add an image of the wound

Browse

evaluate the improvement of the wound

Improved Unchanged Deteriorating

Comments *

Nurse completing form Signature

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