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Introduction

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Patient Name:________________________________________________________Date:________________________________

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Location:________________________________  Tunnel:  _____________ o'clock _____________ cm

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Size (length × width):______________________cm      _____________ o'clock _____________ cm

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Depth:_________________________________ cm      _____________ o'clock _____________ cm

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Wound base: ________ % red      ________ % yellow      ________ % black

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Odor: ________ present ________ absent

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Exudate: ________ color ________ amount

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Dressing Type: ___________________________________________________________________

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Frequency Change: _____________________________________________________________________

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Pertinent Labs: _______________________________________________________________________

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Nutritional Supplements: ______________________________________________________________

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Pressure-Relieving Program/Devices: ___________________________________________________

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Clinician Signature/Title:_____________________________________________________

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