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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section 1, Client Information. Enter the CLIENT NAME, CLIENT ACES ID, DATE OF BIRTH, and CLIENT PROVIDER ONE ID as required.
In the Pressure Injury Description section, assign a PRESSURE INJURY NUMBER and provide a LOCATION DESCRIPTION using the pictorial diagram from form 13-780.
Select the PRESSURE INJURY CLASSIFICATION by checking the appropriate staging option (1, 2, 3, 4, or Unstageable).
Measure the wound dimensions: Length, Width, and Depth. Indicate any tunneling or undermining if applicable.
Assess WOUND EXUDATE by selecting the saturation level of dressing and describe any odor present.
Evaluate the WOUND BED condition and provide comments on granulation, slough, or necrotic tissue.
Rate PAIN SCALE from 0 (No Pain) to 10 (Worst Pain Imaginable) based on client feedback.
Document observations regarding SURROUNDING SKIN conditions such as erythema or edema.
Finally, ensure RN SIGNATURE is included along with PRINTED RN NAME and DATE before submitting your completed form.
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