Diabetic Foot Ulcer Evaluation/Follow-Up Note

Date/Time: [Encounter date and time]

Patient: [Patient name and identifiers]

Provider/Role: [Clinician name and role]

Visit Type: [Initial Evaluation / Follow-Up]

Setting: [clinic / hospital inpatient / emergency department / skilled nursing facility / home health / telehealth / other]

Chief Complaint

[One-line reason for visit and ulcer(s) addressed, including laterality and location]

History of Present Illness

[Ulcer identifier(s), laterality, anatomic location, and timeframe]

(For Follow-Up visits, emphasize interval changes:) [Interval changes since last visit: drainage, odor, pain, swelling, redness, fevers/chills] [Wound care performed and adherence: cleansing, dressings used, change frequency, who performs] [Offloading device used, approximate hours/day worn, barriers or intolerance] [Antibiotic course and response if applicable] [Any new trauma, pressure injury, or footwear issues]

(For Initial Evaluation, include:) [Onset and precipitating event] [Prior treatments and response] [Previous evaluations or care settings]

[Relevant medical context: diabetes type and duration; most recent A1c with date; neuropathy/LOPS status; nephropathy/CKD/ESRD; retinopathy; PAD history and prior interventions; prior ulcer/amputation/Charcot; smoking status; relevant allergies] (If unknown, explicitly state "Unknown" with reason.)

(Omit ROS unless constitutional symptoms or claudication influence management.)

Examination

Vitals/General

• [Vital signs] (Include temperature when infection is a concern.)
• [General appearance, distress level, ambulatory status, gait devices used]

Lower Extremity Exam

• Skin/Structure: [Temperature asymmetry, edema, erythema, deformity/Charcot features, callus/corns, other notable findings with laterality]
• Neurologic: [LOPS present / LOPS absent / indeterminate]; Method: [10g monofilament / Ipswich touch / vibration / other] (If not assessed, state "Not assessed" with reason.)
• Vascular: [DP and PT pulses bilaterally: palpable / diminished / absent] [Doppler waveform quality if performed] [Objective perfusion data with dates: ABI/TBI/toe pressures/TcPO₂] (If not assessed, state "Not assessed" with reason.)

Ulcer Assessment

(Create a separate block for each ulcer.)

• Ulcer ID: [Unique identifier]; Laterality/Location: [Side and anatomic site]; Suspected etiology: [neuropathic / ischemic / neuro-ischemic / other]
• Measurements: [Length × Width × Depth in cm]; [pre-debridement / post-debridement]; [Undermining: depth and clock-face orientation if present]; [Tunneling: depth and direction if present]
• Wound bed: [Tissue types with approximate percentages: granulation, slough, eschar, necrosis]; Edges: [attached / rolled / macerated / callused]; Periwound: [condition]
• Drainage: [none / scant / small / moderate / large]; [serous / serosanguinous / purulent]; Odor: [none / present]
• Depth/exposure: [Exposed structures: tendon / capsule / bone / none]; Probe-to-bone: [positive / negative / not performed]

Infection Status

• Local signs: [Erythema extent in cm from wound edge, warmth, swelling, tenderness, purulence]
• Systemic signs: [Fever/chills, tachycardia, hypotension, other] (Include only if present.)
• Clinical severity: [Uninfected / Mild / Moderate / Severe]
• Osteomyelitis concern: [Present / Absent / Uncertain] (Provide supporting evidence: probe-to-bone result, imaging findings, ESR/CRP, exposed bone.)
• Culture: [Obtained / Not obtained]; [tissue / swab / bone]; [Site and date]

Data Reviewed/Ordered

• Reviewed: [Labs with dates: A1c, ESR/CRP, CBC, renal function] [Imaging with dates: X-ray/MRI findings] [Culture results with dates]
• Ordered: [Labs, imaging, cultures ordered with indications]

(If any required element is not documented, state "Not assessed" or "Unable to assess" with reason.)

Assessment

(Number problems by clinical priority; limb- or life-threatening issues first.)

1. [Problem and synthesis] (For each ulcer: status [improving / stable / worsening] with objective support such as measurement trend or drainage change; infection status and severity; ischemia/PAD status and adequacy for healing. Note osteomyelitis concern prominently if present. Label findings as patient-reported when applicable.)
2. [Additional problems as needed: contributing conditions such as diabetes control, PAD, neuropathy, foot deformity, CKD/ESRD, smoking, malnutrition, offloading adherence, social barriers]

Plan

Wound Care

• [Cleansing method]
• Debridement: [none indicated / performed today / scheduled with frequency]
• Dressing regimen: [Primary dressing type and purpose; secondary dressing; change frequency]
• [Periwound protection if indicated] (If topical antimicrobial used, state indication.)

Offloading

• Device: [total contact cast / non-removable walker / removable walker / healing sandal / felted foam / custom footwear / other]
• Non-removable: [yes / no]
• [Weight-bearing instructions]
• [Adherence strategy and education] (If standard offloading contraindicated or not tolerated, document reason and alternative.)

Infection Management

• (If infected:) [Antibiotic: drug/dose/route/duration]; [empiric / targeted]; [Culture plan]
• [Osteomyelitis workup: imaging and labs ordered with rationale]
• Hospitalization/urgent surgical evaluation: [indicated / not indicated] (Include rationale if indicated.)
• (If uninfected:) No clinical infection—antibiotics not indicated.

Vascular Management

• [Perfusion tests reviewed or ordered with rationale]
• Vascular referral: [urgent / routine / not indicated]; [Rationale]
• [Healing trajectory checkpoint, e.g., reassess if <50% area reduction at 4 weeks]

Medical Optimization

• [Coordination with PCP/endocrinology for glycemic control]
• [Tobacco cessation counseling if applicable]
• [Nutrition optimization/dietitian referral if malnutrition suspected]

Patient Education

• [Offloading importance and safe ambulation]
• [Dressing technique and change schedule]
• [Infection warning signs and when to seek urgent care]
• [Barriers identified and mitigation plan: cost, transportation, dressing changes]

Follow-Up

• [Return interval with rationale] (Shorten for active infection, new offloading device, or marginal perfusion.)
• [Return precautions and escalation triggers]

Procedure Note

(Include only if debridement or other procedure performed.)

• Indication: [Indication for procedure]
• Consent: [Informed consent obtained]
• Method: [sharp / selective / excisional]; [Instruments and technique]
• Tissue depth removed: [skin / subcutaneous / muscle / bone] (Document only tissue actually removed, not merely visible structures.)
• Post-debridement wound surface area: [Length × Width in cm, total cm²]
• Hemostasis: [Method]
• Anesthesia: [Type and amount, or none]
• Complications: [None / describe]
• Dressing applied: [Type]

(General instructions: If information is unavailable or not assessed, include placeholder text indicating absence with reason rather than omitting. Do not infer adherence or improvement without objective evidence or explicit patient report. Avoid auto-imported data not referenced in clinical reasoning.)