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Wound Assessment Form Name:

DOB:

Hospital Number:

NHS Number:

Team/Ward: Nutritional Status:

MUST1 Score:

Factors which may delay healing (e.g. lifestyle, medication, medical condition):

Allergies: Patient Consent to Treatment:- YES / NO Incident report completed for pressure ulcers as per local policy:-

YES / NO / N/A

Equipment used (e.g. mattress, cushion, offloading device):

Wound Type/Grade/Category (EPUAP2):

Identify location of wound below (number if more than one wound):

1 2

Malnutrition Universal Screening Tool (MUST) European Pressure Ulcer Advisory Panel (EPUAP)

Produced by South West Yorkshire Wound Management Group for use in Calderdale, Kirklees, Wakefield and Pontefract District NHS organizations Approved December 2009 Review December 2011

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Wound Evaluation Per Wound Location of Wound:

Initial Assessment Date

Date

Date

Date

Date

Date

Yes / No Yes / No

Yes / No Yes / No

Yes / No Yes / No

Yes / No Yes / No

Yes / No Yes / No

Yes / No Yes / No

Wound Pain (a) None (b) Specific times (c) Dressing change (d) Continuous

Size Length (cm) Breadth (cm) Undermining Depth (cm) Photographed (date)

% of each Tissue Type (a) Epithelialising (b) Healthy granulation (c) Unhealthy granulation (d) Over-granulation (e) Sloughy (f) Necrotic (g) Other

Surrounding Skin (a) Healthy/intact (b) Dry/scaling (c) Eczema (d) Fragile (e) Oedematous (f) Macerated (g) Erythema (h) Excoriation

Wound Odour (a) None (b) Slight (c) Offensive

Wound Exudate (a) Clear (b) Red (c) Green (d) Yellow

Amount of Exudate (a) None (b) Low (c) Medium (d) High/strike through

Infection (a) Infection present (b) Wound swab sent (c) Action taken please state:

Print Name: Signature: Designation: Date:

Produced by South West Yorkshire Wound Management Group for use in Calderdale, Kirklees, Wakefield and Pontefract District NHS organizations Approved December 2009 Review December 2011

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http://www.kirklees.nhs.uk/fileadmin/documents/publications/policies_procedures/Medicines_Management