Wound Care Initial Evaluation Note

Note Type: Wound Care – Initial Evaluation

Date/Time: [Date and time]

Location: [Clinic/facility]

Author/Credentials: [Name, credentials]

Visit Type: [new / consult]

Referral Source: [Referring clinician/service] (Include only if consult; omit if new patient)

Reason for Consult: [Reason] (Include only if consult; omit if new patient)

Photography Consent: [obtained / declined] (Include only if photography discussed or performed; omit otherwise)

Procedure Consent: [obtained / declined] (Include only if procedure planned or performed; omit otherwise)

Chief Complaint

[Patient-stated wound concern in one concise sentence]

History of Present Illness

[Onset and precipitating event] (State exact onset date or best estimate with source. Include mechanism/precipitant and initial location. If onset is unknown, explicitly document as unknown with explanation.)

[Course and current wound characteristics] (Describe trajectory [stable / improving / worsening], changes in size/drainage/odor/pain, aggravating and alleviating factors, prior treatments with responses.)

[Complication symptoms and patient goals] (Document infection indicators, ischemic symptoms such as claudication/rest pain, neuropathic symptoms, and patient-reported goals for care.)

Relevant Medical Background

• Diabetes: [Type, duration, latest A1c with date, glucose control summary] (Include only if applicable)
• Peripheral Arterial/Vascular Disease: [History of PAD/CLTI, revascularization, claudication/rest pain]
• Venous Disease: [Chronic venous insufficiency, DVT/PE history, prior venous procedures]
• Neuropathy: [Peripheral/autonomic neuropathy, symptoms]
• Renal Disease: [CKD stage/ESRD, dialysis modality/frequency]
• Immunosuppression: [Conditions/therapies impacting immunity]
• Nutrition Risk: [Unintentional weight loss, poor intake, albumin/prealbumin if available]
• Tobacco/Nicotine: [Current / former / never; type and quantity]
• Mobility/Offloading Limitations: [Gait aids, wheelchair use, bedbound status, ability to elevate/compress/offload]
• Prior Wounds/Amputations: [Ulcers, osteomyelitis, amputations, grafts/flaps, advanced therapies]
• Relevant Surgical History: [Vascular, orthopedic, podiatric, dermatologic surgeries]
• Wound-Relevant Medications: [Anticoagulants/antiplatelets, immunosuppressants, diabetes meds, current/recent antibiotics with dates, topicals] (If full list elsewhere, state "medications reviewed" and list only wound-relevant agents)
• Allergies/Sensitivities: [Adhesives, topical agents, antibiotics, latex; include reaction type]

Social and Functional Status

• Occupation/Activity: [Work demands; ability to offload/elevate/compress]
• Mobility/Footwear: [Ambulatory status, devices, footwear/inserts]
• Home Support: [Caregiver availability, assistance with dressing changes]
• Barriers to Care: [Transportation, supply affordability, health literacy]

Review of Systems

(Document pertinent positives and negatives only; omit systems without relevant findings)

• Constitutional: [Fever, chills, malaise]
• Vascular: [Claudication, rest pain, dependent rubor]
• Neurologic: [Numbness, tingling, burning, weakness]
• Skin: [New wounds, spreading erythema, increased drainage/odor]
• Endocrine: [Polyuria, polydipsia, hypoglycemia symptoms] (Include only if relevant)

Physical Examination

Vitals and General

• Vitals: [Vital signs including temperature]
• General: [Appearance, distress level, toxicity]
• Weight/BMI: [Weight, BMI] (Include if relevant to nutrition or edema assessment)

Vascular Examination

(Include for lower-extremity wounds or when perfusion/compression decisions are being made)

• Pulses: [Dorsalis pedis, posterior tibial, femoral; presence/quality; laterality]
• Capillary refill: [Time and location]
• Skin temperature/color: [Cool/warm; pallor/rubor; dependent changes]
• Edema: [Pitting / non-pitting; severity; distribution; laterality]
• Venous disease signs: [Varicosities, stasis dermatitis, lipodermatosclerosis, atrophie blanche]

Neurologic Examination

(Include for diabetic foot or suspected neuropathic ulcers)

• Protective sensation: [Method and results, e.g., 10g monofilament sites tested and score]
• Motor/gait: [Weakness, deformity impact, assistive devices]
• Autonomic findings: [Anhidrosis, skin fissuring] (If relevant)

Foot Examination

(Include for diabetic or neuropathic foot wounds)

• Deformities: [Hammertoes, hallux valgus/rigidus, midfoot collapse, Charcot changes]
• Callus/pressure points: [Location and severity]
• Nail and skin integrity: [Findings]
• Footwear assessment: [Current footwear adequacy, orthotics]

Wound Assessment

Wound Inventory: [List each wound: identifier (e.g., W1, W2), location with laterality, suspected etiology, baseline size] (Use stable identifiers that persist across visits)

Wound [ID]: [Location summary]

Location: [Laterality, anatomic region, landmarks]

Type/Etiology and Classification: [Wound type and appropriate staging/classification] (Use NPIAP staging for pressure injuries only; Wagner or clinic-standard for diabetic foot ulcers; CEAP for venous if used; WIfI for arterial/CLTI if used. Do not apply pressure injury staging to non-pressure wounds. If uncertain, state "classification deferred" with reason and testing needed.)

Measurements: [Length × width × depth in cm; undermining/tunneling with depth and clock-face location] (Note measurement conditions if relevant: after cleansing, limited by pain, obscured by eschar)

Wound Bed: [Tissue types with approximate proportions; exposed structures or foreign material if present]

Edges and Periwound: [Edge characteristics: rolled/epibole / undermined / attached; periwound: maceration, erythema, induration, dermatitis, callus, moisture damage]

Exudate: [Amount: none / light / moderate / heavy] [Type: serous / serosanguinous / purulent] [Odor: none / mild / strong]

Pain: [Score and quality; note if dressing-change pain differs from baseline]

Infection Assessment: [Local signs: warmth, erythema with extent in cm, swelling, purulence; systemic signs if present] (For diabetic foot infection, include IDSA severity classification and supporting findings)

Photo Documentation: [obtained / declined / not obtained] [Reason if not obtained; reference scale: used / not used]

Wound [ID]: [Location summary]

(Repeat the above wound format for each additional wound)

Diagnostics

• Laboratory data: [CBC, CMP, A1c, inflammatory markers with dates and relevant values]
• Imaging: [Plain films/MRI/CT/US with dates and key findings]
• Vascular studies: [ABI, TBI, toe pressures, duplex with dates and results]
• Critical data gaps: [What is missing, clinical significance, what is being ordered, interim precautions] (Explicitly document if perfusion assessment is needed before compression or aggressive debridement)

Assessment

(Problem-oriented format; order by clinical severity)

[Problem number]: [Diagnosis with etiology, location, chronicity]

• Classification/Stage: [Stage/grade with supporting criteria]
• Key barriers to healing: [Perfusion, pressure, edema, infection, glycemic control, nutrition, adherence]
• Differential diagnosis: [Alternatives if etiology uncertain] (Label suspected etiologies as "suspected [etiology], pending [confirmation test]")

(Repeat for additional problems as needed)

Plan

(Organize by wound or problem if multiple exist)

Goals

• Treatment intent: [healing / palliation / maintenance]
• Reassessment targets: [Time-oriented milestones]

Local Wound Care

• Cleansing: [Solution and technique]
• Debridement: [Type, prerequisites, frequency]
• Topicals: [Agents with indications]
• Dressings: [Primary and secondary products, change frequency, responsible party]

Etiology-Directed Therapy

• Offloading/pressure redistribution: [Device/footwear; adherence strategy]
• Compression therapy: [Rationale, prerequisites, type/level, monitoring plan]
• Vascular evaluation: [Testing/referral, urgency, revascularization considerations]
• Infection management: [Cultures obtained, antibiotics with duration, imaging for osteomyelitis if indicated]
• Glycemic optimization: [Coordination with PCP/endocrinology; targets]
• Nutrition: [Screening results; supplements; dietitian referral]
• Pain management: [Baseline and dressing-change strategies]

Patient Education

• Topics covered: [Content taught, recipient, teach-back used: yes / no]
• Warning signs: [Signs requiring urgent evaluation]
• Activity modifications: [Restrictions and self-care instructions]

Follow-up

• Next visit: [Timeframe]
• Reassessment plan: [What will be evaluated; escalation criteria]

Supplies/DME Orders

• Wound descriptors: [Wound type, location, current size (L × W × D), drainage amount]
• Order details: [Product category, change frequency, quantity, duration, responsible party]
• Missing information: [If required descriptors unavailable, document reason and interim plan]

Orders Placed

• Labs: [Orders]
• Imaging: [Orders]
• Vascular studies: [Orders]
• Referrals: [Vascular surgery, podiatry, infectious disease, endocrinology, nutrition, PT/OT, home health]
• DME/Supplies: [Orders]
• Medications: [Orders]

Procedure Performed Today

(Include this section only if a procedure was performed; omit entirely otherwise)

• Procedure: [Name] Indication: [Reason]
• Consent: [Obtained; risks/benefits/alternatives discussed]
• Pre-procedure wound: [Description and measurements]
• Anesthesia/analgesia: [Agent, dose, route]
• Technique: [Method, instruments, sterile prep]
• Tissue removed: [Type and depth/level achieved]
• Hemostasis: [Method]
• Complications/tolerance: [None / describe]
• Post-procedure measurements: [Updated L × W × D]
• Dressing applied: [Type and layers]
• Post-procedure instructions: [Care, activity, warning signs]

Care Coordination

(Include only if coordination occurred; omit section entirely if none)

• [Referring clinician updated]
• [Family/caregiver contacted]
• [Home health instructions transmitted]