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M & M HOME CARE WOUND CARE TREATMENT FLOWSHEET
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WOUND INFORMATION
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WOUND TYPE
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WOUND TYPE DEFINITIONS
Trauma: A wound that resulted from an unintentional injury or accident.
Pressure Ulcer: Any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually over bony prominences and re staged to classify the degree of tissue damage observed.
Surgical Wound: A wound caused by a surgical intervention. Orthopedic pin sites, central lines (excluding PICCS), stapled or sutured incisions, debrided graft sites and wounds with drains are all considered surgical wounds.
Diabetic Wound: A chronic wound of the foot that occurs in patients with diabetes. It is caused by loss of sensation and feeling in the lower extremities.
Venous Insufficiency: An ulcer caused by inadequate venous circulation, usually lower legs. Lesions usually weeping and with irregular wound edges.
Arterial Insufficiency: An ulcer caused by inadequate arterial circulation usually located distally small, dry lesions with well defined borders. (punch-out lesions).
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PREVIOUS TREATMENTS
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WOUND BED ASSESSMENT
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WOUND BED
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EXUDATE AMOUNT
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EXUDATE TYPE
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ODOR?
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WOUND EDGES
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SURROUNDING SKIN
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IS THE WOUND:
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CURRENT TREATMENT(S)
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FOLLOW UP PLAN(S)
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ELECTRONIC SIGNATURE
By selecting the "SUBMIT" button, you are signing this Agreement electronically. You agree your electronic signature (hereafter referred to as your "E-Signature") is the legal equivalent of your manual/handwritten signature on this Agreement.
By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.
Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.
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I understand this is a legal representation of my signature.
Clear
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