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Wound Exam Notes Generator

Wound Exam Notes Generator

Wound Exam Notes Generator

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





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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
Topic 40 Version 1.0