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    Wound Care Patient Assessment Chart

    Uploaded by

    Brian Harris
    The document is a wound care patient assessment chart that collects information about a patient's wound history and current condition. It documents details like the patient's name and date of birth, how long the wound has been present, any factors that could delay healing, previous treatment history, the type and location of wound, its dimensions and nature of the wound bed. It also assesses risks, checks the condition of skin around the wound, documents any changes in the wound's size, the percentage of wound bed covered and exudate levels. The chart notes the surrounding skin condition, any pain or odor, any samples taken or treatment, and the type of dressing used.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Wound Care Patient Assessment Chart

    Uploaded by

    Brian Harris
    244 views2 pages
    The document is a wound care patient assessment chart that collects information about a patient's wound history and current condition. It documents details like the patient's name and date of birth, how long the wound has been present, any factors that could delay healing, previous treatment history, the type and location of wound, its dimensions and nature of the wound bed. It also assesses risks, checks the condition of skin around the wound, documents any changes in the wound's size, the percentage of wound bed covered and exudate levels. The chart notes the surrounding skin condition, any pain or odor, any samples taken or treatment, and the type of dressing used.

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    The document is a wound care patient assessment chart that collects information about a patient's wound history and current condition. It documents details like the patient's name and date of birth, how long the wound has been present, any factors that could delay healing, previous treatment history, the type and location of wound, its dimensions and nature of the wound bed. It also assesses risks, checks the condition of skin around the wound, documents any changes in the wound's size, the percentage of wound bed covered and exudate levels. The chart notes the surrounding skin condition, any pain or odor, any samples taken or treatment, and the type of dressing used.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    244 views2 pages

    Wound Care Patient Assessment Chart

    Uploaded by

    Brian Harris
    The document is a wound care patient assessment chart that collects information about a patient's wound history and current condition. It documents details like the patient's name and date of birth, how long the wound has been present, any factors that could delay healing, previous treatment history, the type and location of wound, its dimensions and nature of the wound bed. It also assesses risks, checks the condition of skin around the wound, documents any changes in the wound's size, the percentage of wound bed covered and exudate levels. The chart notes the surrounding skin condition, any pain or odor, any samples taken or treatment, and the type of dressing used.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    of 2

    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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