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Click ‘Get Form’ to open the skin observation form in the editor.
Begin by entering the CLIENT NAME and CLIENT ID at the top of the form. This information is essential for identifying the patient.
Next, specify the DATE of assessment to ensure accurate documentation.
In the LOCATION OF WOUND section, describe the wound's position on the body and use the pictorial diagram provided to indicate its exact location.
For CLASSIFICATION STAGING, check one box corresponding to the wound stage (1 through 4) based on your assessment.
Measure the wound dimensions by filling in Length, Width, and Depth. If you estimate depth visually, indicate 'Yes' and provide a description if applicable.
Assess Wound Exudate by selecting one of the saturation options that best describes your findings.
Evaluate WOUND PAIN and mark whether there is pain present or not. If pain exists, rate it using a scale from 0 to 10.
Document any ODOR present by indicating 'Yes' or 'No' and providing details if necessary.
Examine SURROUNDING SKIN for signs like Erythema or Edema and describe your observations in detail.
Check for TUNNELING and UNDERMINING; if present, provide descriptions as needed.
Assess the WOUND BED condition (Granulation, Necrotic, etc.) and describe it accordingly.
Finally, add any NOTES regarding current treatments and recommendations before signing off with RN SIGNATURE and DATE.
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