ST



AGENCY NAME TYPE:

SKIN TEAR

INCISION

EXCORIATION

WOUND CARE FLOW SHEET PRESSURE

LEG ULCER

FOOT ULCER

|DATE | | | | | | | |

|TIME | | | | | | | |

|SITE# | | | | | | | |

|TYPE | | | | | | | |

|STAGE: | | | | | | | |

|PRESSURE ONLY | | | | | | | |

|GRANULATION | | | | | | | |

|SLOUGH/ESCHAR | | | | | | | |

|DRAINAGE | | | | | | | |

|# OF DRSG. SATURATED | | | | | | | |

|+DESCRIPTION | | | | | | | |

|SURROUNDING SKIN | | | | | | | |

|SIZE: | | | | | | | |

|DONE WEEKLY | | | | | | | |

|TEMPERATURE | | | | | | | |

Plan of Care:___________________________________________ PRESSURE ONLY

STAGE:

I. Nonblanchable erythema of intact skin

II. Partial-thickness skin loss involving epidermis and / or dermis

III. Fill thickness involving damage or necrosis of

Subcutaneous tissue, may extend to but not through fascia

IV. Full-thickness with extensive destruction; tissue necrosis or

Damage to muscle bone or supporting structure

O. Unable to stage –necrotic tissue

Physician and Phone: EXUDATE (Drainage)

Amount Small, Moderate, Large

Type Serous

Serosanguineous

Sanguineous

Case Manager:_________________________________________ Odor Purulent

LOCATION: Indicate on drawing

Staff Signatures: (1)_____________________________________

(2)__________________________(3)_______________________

(4)__________________________(5)_______________________

(6)__________________________(7)_______________________

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