Appendix 8: Initial Wound Assessment and Treatment Plan

Introduction

Patient Name:

Date of Evaluation:

Location:

Type:

Measurements (Length x Width x Depth):

Wound Base:

Signs/Symptoms of Infection (Yes/No):

Girth Measures:

Sensation:

Peripheral Pulses:

Other Tests (TCP0₂, Vascular Studies, X-Rays, Labs, etc.):

Consultations (MD, Rehab, Social Services, Home Health, Diabetes Education, etc.):

Treatment Plan (include plan, DME, home dressing supplies):

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