Wound care consultation

OVERALL_INSTRUCTIONS

Chief Complaint

Wound care consultation for assessment and management.

Template

Wound Care Note Patient Identification: [Patient name, age, gender, relevant medical history] History of Present Illness: [Description of wound onset, mechanism of injury, duration, associated symptoms, previous treatments] Past Medical History: (hyphenated list) - [Relevant medical conditions] Medications: (hyphenated list) - [Medication name, dose, route, frequency] Allergies: (hyphenated list) - [Allergen and reaction] Social History: (hyphenated list) - [Tobacco use] - [Alcohol use] - [Recreational drug use] - [Occupation] - [Living situation] Wound Assessment: (hyphenated list) - [Location of wound] - [Size (length x width x depth in cm)] - [Shape] - [Wound bed appearance (granulation, slough, eschar)] - [Exudate (type, amount, odor)] - [Surrounding skin (erythema, edema, induration)] - [Signs of infection (warmth, tenderness, purulence)] - [Pain (severity, character)] - [Other findings (e.g., tunneling, undermining, exposed structures)] Physical Examination: (hyphenated list) - [Vital signs with units] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [Relevant system exam findings] Investigations: (hyphenated list) - [Wound cultures] - [Imaging studies] - [Laboratory results] Assessment: (hyphenated list) - [Diagnosis and reasoning] - [Complicating factors (e.g., diabetes, vascular disease)] Plan: (hyphenated list) - [Wound care interventions (cleansing, debridement, dressing type)] - [Medications (antibiotics, analgesics)] - [Adjunct therapies (negative pressure, topical agents)] - [Patient education and counselling] - [Referrals (e.g., surgery, infectious disease, vascular)] - [Follow up plan] - [Return precautions]