MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation
MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation
MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation
MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation
MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation
WMR12208/18 M
R 1
22W
ound
Ass
essm
ent &
Man
agem
ent P
lan
WMR122 HCWZZFMR0122 FOB BLACK PMS 306
Wound Assessment & Management Plan
Hospital / Health Service
Doctor:
Ward:
SURNAME
GIVEN NAMES DOB
TELEPHONE
GENDER
ADDRESS POSTCODE
UMRN / MRN
Please use I.D. label or block printH
CW
ZZFM
R01
22
XC
3003
40
Right Right
LeftLeft
RL RL
RL RL
Right Right
LeftLeft
RL RL
RL RL
L R
R L
MR
122
W
ound
Ass
essm
ent &
Man
agem
ent P
lan
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Identify location of wound on diagram below. If multiple wounds, use a separate form for each.
Skin Tear Pressure Injury Leg/Foot Ulcer Surgical or other wound STAR classification:
1a 1b 2a 2b 3 Unsure
Stage: 1 2 3 4 Unstageable Suspected Deep Tissue Injury
Venous Neuropathic Arterial Neuroischaemic Mixed Unsure
ABPI (L): ABPI (R):
Describe:
Factors Impairing Healing:
Diabetes Infection Obesity Malignancy Advanced age Autoimmune conditions
Smoking Ischaemia Poor nutrition Medication Other:
Location of Wound:
Assessment Date: Date: Date:
Dimensions Length mm mm mm
Width mm mm mm
Depth mm mm mm Wound Appearance
Epithelialisation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Granulation (red) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Slough (cream / yellow) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Necrotic (black / grey / brown) 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100%
Hypergranulation 0 25 50 75 100% 0 25 50 75 100% 0 25 50 75 100% Other (specify)
Wound Edges Pink / Red
Purple / Black Raised
Undermined / Cavity Surrounding Skin
Normal Erythema (redness)
Oedema Dry / Scaly
Fragile / Thin Maceration
Other (specify)
Exudate: Amount and Type Nil Low Mod Heavy
Nil Low Mod Heavy
Nil Low Mod Heavy
Serous (clear / straw) Haemoserous (pale pink / straw)
Purulent (pus, creamy) Sanguinous (bright blood)
Other (specify) Odour Nil Malodour Nil Malodour Nil Malodour
Wound Pain Score: /10 Score: /10 Score: /10
Patient’s description of pain
Digital Record No Photo No Photo No Photo Infection - Swab Taken No Yes No Yes No Yes
Signature & Designation
Complete Pressure Injury Alert sticker and stick in progress notes
WMR122 HCWZZFMR0122.indd 1 3/8/18 2:01 pm
Please use ID Label or block print
_______________________ Hospital / Health Service
Wound Assessment & Management Plan
Ward:
Doctor:
Surname UMRN / MRN
Given Name DOB Gender
Address Postcode
Telephone
Allergies / Alerts / Skin sensitivities: Referrals sent to:
Plan developed in partnership with Patient/Carer: _____/_____/_____ Patient/Carer Signature: _______________ Frequency (eg daily, 2nd daily): Analgesia prior: Yes No
Goals of care: Moisture balance Bacterial balance Debridement Comfort Other: Cleanse with: N/Saline H2O Other: Care of peri-wound skin:
Primary Dressing:
Secondary Dressing:
Fixation / Bandaging:
Comments:
Name: Signature: Designation:
Date ceased / revised: _____ / _____ / ______ Reason:
Frequency (eg daily, 2nd daily): Analgesia prior: Yes No
Goals of care: Moisture balance Bacterial balance Debridement Comfort Other: Cleanse with: N/Saline H2O Other: Care of peri-wound skin:
Primary Dressing:
Secondary Dressing:
Fixation / Bandaging:
Comments:
Name: Signature: Designation:
Date ceased / revised: _____ / _____ / ______ Reason:
Frequency (eg daily, 2nd daily): Analgesia prior: Yes No
Goals of care: Moisture balance Bacterial balance Debridement Comfort Other: Cleanse with: N/Saline H2O Other: Care of peri-wound skin:
Primary Dressing:
Secondary Dressing:
Fixation / Bandaging:
Comments:
Name: Signature: Designation:
Date ceased / revised: _____ / _____ / ______ Reason:
Record of Dressing Attended Date Dressing
Attended Date
Next Due Print Name Initials Date Dressing Attended
Date Next Due Print Name Initials
1 7
2 8
3 9
4 10
5 11
6 12 WACHS version 5 November 2015
Plan developed in partnership with Patient/Carer: _____/_____/_____ Patient/Carer Signature: _______________
Plan developed in partnership with Patient/Carer: _____/_____/_____ Patient/Carer Signature: _______________
WACHS version 10 August 2018
WMR122 HCWZZFMR0122 BOB BLACK
SURNAME
GIVEN NAMES DOB
TELEPHONE
GENDER
ADDRESS POSTCODE
UMRN / MRN
Please use I.D. label or block print
Wound Assessment & Management Plan
Hospital / Health Service
Doctor:
Ward:
WMR122 HCWZZFMR0122.indd 2 3/8/18 2:01 pm