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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:_____________________________________________________