Initial assessment

SITE:________________________________________________________________________________________

Status: ☐ Being Treated ☐ Closed ☐ Amputated 

Surgical Date: _______________ Date Onset: ___________ 

Pre- Debridement Measurement Length:_________ Width: __________ Depth: _________ 

Undermining 

1. __________ cm, from _________ to _________ o’clock

2. __________ cm, from _________ to _________ o’clock 

3. __________ cm, from _________ to _________ o’clock 

Tunneling/Sinus 

1. ______________cm, @ ___________ o’clock 

2. ______________cm, @ ___________ o’clock 

3. ______________cm, @ ___________ o’clock 

Assoc. Signs/Symptoms: ☐ Pain ☐ Numbness ☐ Tingling ☐ Swelling ☐ Draining ☐ Bruising ☐ Hot ☐ Erythema ☐ Odor ☐ None ☐ Other: ______________________ 

Wound Depth: ☐ Skin ☐ Sub Q ☐ Muscle ☐ bone ☐ Closed ☐ Epithelialized ☐ Unstageable Bone / Muscle / 

Tendon Exposed: ☐ No ☐ Yes 

Wound Odor: ☐ No Odor ☐ Malodorous ☐ Other: ______________ 

Periwound Skin: ☐ No Abnormalities ☐ Ecchymosed (bruised) ☐ Erythematous (red) ☐ Indurated (firm) ☐ Edematous (swollen) ☐ Maceration ☐ Callous ☐ Other:__________________________________________ 

Exudate: Amount: ☐ None ☐ Small ☐ Moderate ☐ Large ☐ Other:________________________ 

Color: ☐ Serous (clear) ☐ Sanguinous (bloody) ☐ Serosanguinous (blood-tinged) ☐ Yellow ☐ Green ☐ Tan (colonized) ☐ Other: _________________________________ 

Consistency: ☐ Thick ☐ Thin ☐ Milky ☐ Purulent ☐ Other: __________________

 EMR notes

assessment of improvement

Granulation:_______% Hypergranulation:___________% Fibrin:____________% Eschar:__________________% 

Assessment of progress since last visit:

Drainage: ☐ No Visible Change  ☐ Less ☐ More

Inflammation: ☐ No Visible Change ☐ Less ☐ More ☐ Evidence Infection

Swelling: ☐ No Visible Change ☐ Less ☐ More

Pain: ☐ No Visible Change ☐ Less ☐ More

Wound dimensions (diameter): ☐ No Visible change  ☐ smaller ☐ larger

Wound dimensions (deeper): ☐ No Visible change ☐ deeper ☐ shallower                                          

Necrotic tissue/slough: ☐ No Visible Change ☐ Less ☐ More

Increased Wound Debris: ☐ No Visible Change ☐ Less ☐ More

Other: _________________________________________

 EMR notes

Debridement

Start: _________________ End: ______________________ 

☐ Excisional ☐ Non-Excisional ☐ 

Other: _________________________________________ 

☐ Verify 2 patient identifiers 

☐ Consent signed 

☐ Verbal verification of procedure w/patient

 ☐ H&P or wound assessment performed 

☐ Site marked or physician remained with pt after assess. 

Anesthesia ☐ None ☐ Xylocaine Viscous 2% | 4% ☐ Other: _________________________________________

Depth of Debridement ☐ Skin ☐ Subcutaneous ☐ Muscle ☐ Bone

Tissue Removed ☐ Fibrin ☐ Devitalized Epidermis/ Dermis ☐ Debris ☐ Necrotic ☐ Biofilm

Method of Debridement ☐ Scalpel ☐ Scissors ☐ Curette ☐ Other: _________________________________________ 

Bleeding ☐ None ☐ Minimal ☐ Moderate ☐ Marked 

Hemostasis Achieved ☐ Pressure ☐ AgNO3 ☐ Cautery ☐ Other: _________________________________________

Procedure Pain ______/10

Post- Debridement Measurement Length: ________ Width:__________ Depth:_________

 EMR notes