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WOUND ASSESSMENT CHART

PATIENTS NAME:
DOB:
HOSPITAL/NHS NUMBER:

TYPE OF WOUND & LOCATION (if pressure damage include


stage & date reported on Datix):

WOUND LOCATION

LR

LR

LR L R L R
L
Lateral

L RR L

RR

LR
LR
L
RLLR L R R LR R L R RL

LR
LRRLL
L L

RR

RL R R LR

L L

Medial
Dorsal
Sole DorsalDorsal
Lateral Lateral
LateralLateral
Medial
Lateral
Medial
Medial
Dorsal
Medial
Medial
Dorsal
Sole
DorsalSole Sole Sole
Sole

PLEASE TICK WOUND TYPE (complete separate sheet for each wound)
Pressure Ulcer
Moisture Lesion
Burn/Scald
Fungating Wound
Skin Tear / Laceration
Leg Ulcer
WOUND DURATION
Acute (<6 wks)
ALLERGIES (include dressing products):

Diabetic Foot Ulcer


Sinus/Fistula
Other:
Chronic (>6 wks)

PATIENT FACTORS WHICH MAY DELAY WOUND


HEALING (eg:Diabetes, Infection, Nutritional status, Medication)

Traumatic Wound
Surgical Wound (dehiscence)

Does patient
have Mental
Capacity ?

Has patient
consented to
treatment ?

YES / NO

YES / NO

Or is care in the
patients best
interest?
YES / NO

PAIN ASSESSMENT
SEVERITY
FREQUENCY

0
1
At Dressing Change

4
On Movement

6
Continuous

8
Other

10

PRESSURE RELIEVING EQUIPMENT IN USE?


MATTRESS: YES/NO Date ordered?
CUSHION:
YES/NO Date ordered?
INITIAL ASSESSMENT:
Wound bed condition (100%)

HEEL PROTECTION
OTHER:
WOUND SIZE
(in CM)

YES/NO Date ordered?


YES/NO Date ordered?
EUPAP CLASSIFICATION
( Pressure ulcer grade/stage)

Epithelising

Width

Healthy Granulation

Length

Slough (Yellow/brown)

Depth

Necrotic (black/brown)

Undermining

Over granulation

Tracking

ABPI (Leg Ulcer)


DATE

LEFT

RIGHT

CONDITION OF SURROUNDING SKIN

Mixed Tissue
Fungating / Malignant
Bone / Tendon / Ligament

Healthy/intact
Macerated

Dry/cracked
Eczematous

Discoloured
Oedematous

Fragile
Excoriated

FURTHER BASELINE ASSESSMENT

Cellulitic

PHOTOGRAPH TAKEN

Infected/critically colonised

YES/NO

WOUND MAPPED

YES/NO

INFECTION SUSPECTED
Wound swab?

Date taken:

Result:

Antibiotic therapy?

Antimicrobial ?

INITIAL WOUND MANAGEMENT PLAN


Wound
Management Aims:
Debridement method

Debride
Reduce Bacterial load

Deslough
Reduce Odour

Protect
Keep Dry
Cleansing Solution

Hydrate
Encourage granulation

Barrier preparation/adhesive remover

Other Instructions:

Primary Dressing

Secondary Dressing

Fixation method/ Bandaging

Frequency of Dressing change

Reassessment Frequency:

Weekly

Referral Required? TVN


Reason for Referral:

Foot Health

Assessed by:

Monthly

Plastics

Next Reassessment Date

Vascular

Dietician

Name:

Signature:

Designation

Date

Other:

09/14 WVG969

WOUND ASSESSMENT CHART


TYPE OF WOUND & LOCATION (if pressure damage include stage

PATIENTS NAME:
DOB:
HOSPITAL/NHS NUMBER:

& date reported on Datix):

ALLERGIES (include dressing products):


DATE:

Wound Bed Condition (100%)


Epithelialisation
Healthy Granulation
Slough
Black/brown necrotic tissue
Over granulating
Fungating/malignant
Mixed tissue (bone/tendon/ligament)
Amount & Colour of Exudate
None
Low
Moderate
Heavy
Size of Wound
Width (W)
Length (L)
Depth (D)
Undermining /Tracking
Odour

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

Wound Pain

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

Wound Mapped (attach grid)

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

Wound Photographed

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

Updated Management Plan

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

Severity (patients score 1-10)


Infection
Nil
Suspected
Swab sent (date)
Infection confirmed
Condition of Surrounding Skin
Healthy/intact
Dry/cracked
Discoloured
Fragile
Macerated
Eczematous
Oedematous
Excoriated

Cleansing Solution
Primary Dressing
Secondary Dressing
Fixation method/ Bandaging
Others: (Barrier prep/adhesive remover)
Frequency of Dressing change
Reassessment frequency: Weekly, Monthly
Referral Required? Please specify:
Assessment completed by (Print & Sign)