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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