Wound Care Patient Assessment Chart

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WOUND CARE: PATIENT ASSESSMENT CHART

Section 1

MANAGED HEALTHCARE

PATIENT DETAILS

Patient name/s: _____________________________________________________ Date of birth: D D / M M / Y Y Y Y


Membership number:
Doctor:______________________________________________________________________________________________

Section 2

PATIENT history

Length of time wound present: ____________ days/weeks/months/years (delete where not applicable)
Factors that may delay healing

Authorisation number

Date

Diabetes

Clinic nurse

DD/MM/YYYY

Anaemia

GP

DD/MM/YYYY

Immobility

Dermatologist

DD/MM/YYYY

Medication

Surgeon

DD/MM/YYYY

Allergies

Dietician

DD/MM/YYYY

Poor nutrition

Others

DD/MM/YYYY

Cardiac

DD/MM/YYYY

Non-compliance

DD/MM/YYYY

Other

DD/MM/YYYY

Previous treatment history:_ _____________________________________________________________________________


___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

Section 3

nature of wound

Type of wound:_______________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Location:_ ___________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Dimensions: Length________________ cm/mm Width _ _____________ cm/mm Depth_ _____________ cm/mm
Nature of wound bed:

Healthy

Granulation

Epitheliazation

Sloughy

Necrotic

Exudate (high)

Exudate (moderate)

Exudate (low)

Odour (offensive)

Odour (some)

Odour (none)

Other

Sizwe Medical Fund is administered by Sechaba Medical Solutions (Pty) Ltd.

Section 4

risk assessment

Pressure sore risk assessment scale used:___________________________________________________________________


Dopler reading:_________________________________________ Index:________________________________________
Condition of skin:

Intact

Fair

Poor

Date dressing changed: D D / M M / Y Y Y Y


Dimensions: Length________________ cm/mm Width _ _____________ cm/mm Depth_ _____________ cm/mm
Are the dimensions:

Increasing?

Decreasing?

Wound bed (approximate percentage of cover):

Exudate levels:

High

Surrounding skin:

Macerated

Static?

Necrotic (black)

Sloughy (yellow)

Granulating (red)

Epithelialising (pink)

Moderate

Low

Oedematous

Increasing

Erythema

Fragile

Decreasing
Dry/scaling

Pain:

Continuous

Specific times

Changing

Odour:

Offensive

Some

None

Action taken:

Swab sent

Results

Treatment objectives:

Debridement

Absorption

Hydration

Protection

Type of dressing used:

Allevyn

Ingtrasite Gel

Optisite Flexigrid

Bactrazine

Jelonet/Bactigras

Hydrocolloid

Alginate

Other

Healthy

None

Sizwe Medical Fund is administered by Sechaba Medical Solutions (Pty) Ltd.

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