Please fill out ONE form per wound Goal of Care To Heal 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the Client Name, DOB, and PHN at the top of the form. This information is essential for identifying the patient.
  3. In the Wound Date of Onset section, input the date when the wound first appeared. This helps track healing progress.
  4. Select the Wound Type/Etiology from options like Pressure, Venous, Arterial, etc. If it's a Pressure Ulcer, specify its stage and date.
  5. For Goal of Care, choose from options such as 'To Heal', 'To Maintain', or 'To Monitor/Manage' based on treatment objectives.
  6. Mark the location of the wound with an arrow or an ‘X’. Fill in Wound Measurements (Length, Width, Depth) accurately.
  7. Document Exudate Amount and Type by checking appropriate boxes. Note any Odour present after cleansing.
  8. Assess and record details about Wound Edge and Peri-wound Skin conditions using provided checkboxes.
  9. Finally, complete the Treatment Plan section by documenting treatment dates and initials as required.

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Documentation: Wound Images and Characteristics Etiology: surgical, laceration, burn, abrasion, traumatic, vasculopathy, neoplastic, etc. Type of wound: chronic or acute. Type of ulcer. Location and condition of surrounding skin. Any tissue loss. Clinical appearance of the wound bed and wound edge. Stage of healing.
Wound dressing is defined as a sterile compress acting as a barrier to protect the injured epidermal tissues from outside and promoting the healing process. Dressing is in direct contact with the wound, and a bandage is usually used to hold a dressing in place.
A: A comprehensive wound care note should include patient information, wound characteristics (like size, depth, color, and drainage), treatments applied, patient response to treatment, and any follow-up instructions. This detailed documentation supports both quality patient care and accurate billing.
Wound healing occurs in four stages, haemostasis, inflammation, proliferation and remodelling, and the appearance of the wound will change as the wound heals. The goal of wound management is to understand the different stages of wound healing and treat the wound ingly.
When documenting a wound, start with the location of the wound as defined by the anatomical man. If the wound is a pressure injury, describe the stage of the wound. Then describe the wound bed as to granulation tissue, slough, black eschar, epithelialization, and so on.
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Examples of writing wound care orders: i. Example #1: Wound #1, sacrum pressure ulcer, stage 2 to be cleansed 3 times a week and prn by with NS/wound cleanser, pat dry, apply hydrocolloid dressing or protective foam adhesive dressing.
The primary goal of wound management is to achieve a functional closure with minimal scarring. Preventing infection is important to facilitate the healing process. Most simple, uncomplicated wounds do not need systemic antibiotics but benefit from the use of topical antibiotics.
Surrounding tissue: Describe the color, firmness, and pallor of the surrounding skin. Note any signs of edema or induration, as well as any lesions, scarring, rashes, staining, moisture, or variations in texture. Note any warmth, redness, or tenderness around the wound, as these could indicate infection.

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