Venous Leg Ulcer Clinic Note

Date: [YYYY-MM-DD] Provider: [Clinician name/credentials] Location: [Clinic/site] Visit Type: [New / Follow-up]

Primary Wound Laterality: [Left / Right / Bilateral] Ulcer Status: [Active (CEAP C6) / Healed (CEAP C5) / Prevention visit]

Chief Complaint

[One-line statement of wound location and primary management focus] (Use anatomic precision such as "left medial gaiter area" and the main goal of today's visit.)

History of Present Illness

[Ulcer course since last visit] (Include onset/duration; objective trends since prior dated visit including size, drainage, and pain changes; dressing and compression adherence with who changes, frequency, and barriers; symptoms including pain severity/quality, pruritus, drainage, odor; infection symptoms such as fever/chills, increasing erythema, warmth, purulence.)

[Edema and venous disease background] (Edema pattern—worse evening vs constant, unilateral vs bilateral; prior venous ulcer history; varicose veins; prior venous procedures; DVT/PE history; activity level and calf pump function; elevation habits; lymphedema features.)

[Arterial screen] (Claudication, rest pain, prior PAD testing/interventions.)

[Healing-relevant comorbidities] (Only include if impacting today's management: heart failure, diabetes control, renal disease, nutrition, obesity, smoking, anticoagulation.)

[Patient goals and functional context] (Ability to don/doff compression, caregiver support, barriers to adherence or follow-up.)

(For brief nurse-only dressing visits, document only wound status, adherence, and complications; omit unrelated sections.)

Objective

Vitals: [Vital signs as relevant]

Lower Extremity Exam: (Document both legs unless clearly unilateral.)

• Left leg: [Edema: pitting/non-pitting, grade, distribution]; [Venous skin changes: hyperpigmentation, lipodermatosclerosis, atrophie blanche, dermatitis, varicosities]; [Infection/cellulitis signs: erythema extent, warmth, tenderness, lymphangitis]
• Right leg: [Edema: pitting/non-pitting, grade, distribution]; [Venous skin changes]; [Infection/cellulitis signs]

Vascular Assessment:

• [Pedal pulses: DP/PT palpable/dopplerable/absent by side; capillary refill]
• [ABI and/or ankle pressure/toe pressure/TBI with date obtained and limb specified]
• [Compression safety statement] (Explicitly state whether strong compression is safe today. If perfusion uncertain or borderline, document compression level used and rationale. If ABI/TBI unavailable, state why and mitigation in place.)

Venous Classification: CEAP [C0–C6]; [Active (C6) / Healed (C5)]

Wound Assessment: (Assign stable IDs that persist across visits. Repeat block for each wound.)

W1: [Etiology: venous / mixed / uncertain]; [Anatomic location with laterality]; [Duration]

• Measurements: [Length × Width × Depth in cm]; [Area if calculated]
• Wound bed: [Percent granulation / slough / eschar]
• Edges: [Attached / undermined / rolled / other]
• Undermining/Tunneling: [Present with measurements and clock positions / Absent]
• Exudate: [Amount; type; odor]
• Periwound skin: [Maceration, erythema, dermatitis, induration, other]
• Pain at wound: [Severity 0–10; character; timing]
• Infection assessment: [Local signs: present / absent]; [Systemic signs: present / absent]; [Culture obtained: Yes / No]
• Photo: [Obtained / Not obtained]

W2: (If applicable—follow same structure as W1.)

Diagnostics Reviewed: [Venous duplex date and findings: reflux vs obstruction, superficial vs deep]; [Relevant labs affecting today's decisions] (Omit if none reviewed.)

Assessment

• Primary problem: [Active / Healed] venous leg ulcer, [laterality and anatomic site], CEAP [class]; [Key barriers: edema control, compression intolerance, suspected infection, mixed arterial disease, nonadherence, obesity, impaired mobility] (If mixed etiology suspected, state uncertainty and testing plan.)
• [Additional problems addressed today] (As applicable.)

Plan

Wound Care: [Cleansing method]; [Primary dressing]; [Secondary dressing]; [Change frequency]; [Periwound protection if needed]; Debridement today: [Yes / No—if deferred, state why]

Compression Therapy: (This section must always be explicit and complete.)

• Applied today: [Yes / No] (If no, state contraindication or deferral reason.)
• Compression type: [Multilayer wrap / Inelastic (short-stretch) / Adjustable wrap / Stockings / Other]
• Target pressure: [Ankle pressure in mmHg or stocking class]
• Wear/change schedule: [Continuous daytime / 24-hour wear / Change frequency]
• Tolerance: [Well tolerated / Pain / Itching / Slippage / Numbness-tingling]
• Contraindication status: Arterial disease [excluded / suspected / confirmed]; [CHF status if relevant]
• Adherence supports: [Donning aids / Caregiver training / Adjustable system / Lymphedema therapy referral / Education] (Include if applicable.)

Infection Management: Infection [present / suspected / absent]. (If absent, state antibiotics not indicated.) [Objective findings]; [Culture: Yes / No]; [Antibiotic, dose, route, duration if treating]; [Return precautions]

Venous Intervention Plan: [Duplex status/plan]; [Referral for superficial reflux treatment if indicated]; [Deep obstruction evaluation if indicated]; [Timing: early intervention vs after healing with rationale] (Omit if not applicable.)

Adjunctive Therapies: [IPC with regimen; pentoxifylline with dose/duration; NPWT with eligibility and concurrent compression confirmed; skin substitutes/CTPs with indication and product] (Omit entirely if none.)

Pain Management: [Severity and triggers]; [Pharmacologic plan]; [Nonpharmacologic measures] (Include when pain is significant.)

Recurrence Prevention: [Long-term compression: type/class, wear schedule]; [Daily skin inspection and moisturization]; [Activity and elevation guidance]; [Smoking cessation if applicable]; [Surveillance interval] (Required when ulcer healed or near-healed.)

Follow-up: [Date/timeframe]; [Contingency instructions for worsening pain, drainage, erythema, fever, or wrap intolerance]

Procedure

(Include only if procedure performed today; omit entirely if none.)

Procedure type: [Selective / Excisional (sharp) / Mechanical]; Wound [ID(s)]; [Anatomic location(s)]

• Area debrided: [cm²]; Depth: [Epidermis / Dermis / Subcutaneous / Deeper]
• Tissue removed: [Slough / Necrotic tissue / Biofilm / Callus]
• Instruments: [Curette / Scalpel / Scissors / Forceps / Gauze]
• Anesthesia: [Topical / Local / Systemic / None]
• Hemostasis: [Method]
• Tolerance/complications: [Well tolerated / Adverse event details]
• Post-procedure appearance: [Viable bleeding tissue / Reduced bioburden / Other]
• Dressing/compression applied: [Details with compression level in mmHg]