q RUH q SCH q SPH Addressograph / Label

q Other ____________ NAME: __________________________________

HSN: ____________________________________
WOUND CARE RECORD
Page 1 of 2 D.O.B.: __________________________________

Admission date ________________

Wound date __________________
Type/origin of wound:
 Burn  Skin tear  Blister
 Lower limb:  Venous  Arterial  Mixed  Diabetic
 Surgical
 Pressure ulcer Stage # ______ at initiation of treatment
Deep Tissue Purple or maroon localized area of discoloured intact
Injury skin or blood filled blister
Stage 1 Intact skin. Non-blanching reddened area
Stage 2 Blister or superficial ulcer
Stage 3 Ulcer exposing subcutaneous tissue, presents as a
crater
Stage 4 Ulcer exposing muscle and/or bone
Unstageable Black eschar or slough covering base. Cannot
determine depth

Braden score______ Date and time completed____________

Speciality surface
 Type and date initiated_________________________

Consults Goal
 OT  Healing
 PT  Palliative/Maintenance
 Dietician
 Wound Resource Team

One Wound Per Sheet

Wound Location
Date & Time of Dressing
Change

Pain pre dressing (min)0 1 2 3 4 5 6 7 8 9 10 (max) (min)0 1 2 3 4 5 6 7 8 9 10 (max)

Pain mid dressing (min)0 1 2 3 4 5 6 7 8 9 10 (max) (min)0 1 2 3 4 5 6 7 8 9 10 (max)

Pain post dressing (min)0 1 2 3 4 5 6 7 8 9 10 (max) (min)0 1 2 3 4 5 6 7 8 9 10 (max)

Swab taken (After cleansing)  N/A  Yes, Type __________  N/A  Yes, Type ____________

Picture taken  N/A  Yes  N/A  Yes

Soiled Dressing/Packing Removal

____________ of _____________ ____________ of _____________
Contact & Cover Dressing
____________ of _____________ ____________ of _____________
Removed
(Quantity & type) ____________ of _____________ ____________ of _____________
____________ of _____________ ____________ of_____________
Type Length Type Length
Amount of Packing
_____________ __________cm _____________ ___________cm
Removed

Negative Pressure Type # of Pieces Type # of Pieces

Wound Therapy _____________ _____________ ______________ _____________
Foam Removed _____________ _____________ ______________ _____________
Word Form # 103527 03/13
WOUND CARE RECORD Patient Name: ______________________
Page 2 of 2
HSN: _____________________________
Wound Assessment
Drainage Amount  Dry  Moist  Small  Dry  Moist  Small
(less than 25%)
wound bed wound bed (less than 25%)

 Med  Large Saturated  Med  Large  Saturated

(25-50%) (50-75%) (more than 75%) (25-50%) (50-75%) (more than 75%)
Drainage Type
 Serous  Serosang  Sang  Serous  Serosang  Sang

 Purulent  Other _________  Purulent  Other __________

Odor (After cleansing)  Yes  No  Yes  No
Length Width Depth Length Width Depth
Size:
_____ cm _____ cm _____ cm _____ cm ____ cm _____ cm
Undermining/Tunneling  Absent  Absent
(Location & size)
Undermining – destruction of tissue that  Undermining  Tunneling  Undermining  Tunneling

   
extends under the intact skin along the wound
edge
Tunneling (sinus tract) - destruction of
tissue that occurs in any direction starting
from the wound bed. _____cm _____cm _____cm _____cm
Wound Base Appearance _____ % Red/Pink Granulation _____% Red/Pink Granulation
(Estimate % of each tissue type. _____ % Yellow slough _____ % Yellow slough
Must total 100%.)
_____ % Black/Grey Eschar _____ % Black/Grey Eschar
_____ % Epithelial _____ % Epithelial
_____ % Not Visible _____ % Not Visible
_____ % Other ___________________ _____ % Other ___________________
Wound Edge Appearance
Tick all that apply  Attached  Attached
Attached – even with wound bed
Not-Attached – wound base deeper than  Not Attached  Calloused  Not Attached  Calloused
edge
Demarcated – easy to define wound outline  Punched Out  Punched Out
Diffuse – undefined wound outline
Calloused – thickened  Demarcated  Rolled  Demarcated  Rolled
Punched Out – Distinctive shape with sharp
edged border  Diffuse  Diffuse
Rolled – edges rolled under

Periwound Skin  Firm to  Firm to

 Intact  Erythema  Intact  Erythema
touch touch
 Heat  Macerated  Rash  Heat  Macerated  Rash

Dressing/Packing Application
Irrigation/Cleansing Dual top Dual top
Solution Amount Solution Amount
Syringe Syringe
________ ________ ________ ________
Cath Cath
 Skin Prep  Cavilon  Other  Skin Prep  Cavilon  Other
Periwound Skin Care

Amount of Packing Type Length Type Length

Inserted (Insert one continuous ______________ ___________cm ______________ ____________cm
piece - fluff don’t stuff)
Type # of Pieces Type # of Pieces
_______________ _______________ _______________ _______________
Negative Pressure
_______________ _______________ _______________ _______________
Wound Therapy
Foam Inserted Pressure at  Continuous Pressure at  Continuous
____mmHg  Intermittent ____mmHg  Intermittent
Contact & Cover Dressing ____________ of _____________ ____________ of _____________
Applied ____________ of _____________ ____________ of _____________
(Quantity & type)
____________ of _____________ ____________ of _____________
____________ of _____________ _____________ of _____________
Physician Assessed  Yes  No Name ____________  Yes  No Name ____________
Signature/Title