Education

Wound Tracking Form Weekly

Facility: _________________________________________________________   Unit: ____________________    Date: _______________________

 

Resident

Room

No.

Present on Admit or In-House

 

Location of
Wound

Type of Wound

 

Stage/
Pressure Previous Week

Stage/
Pressure Current Week

Treatments

Treatment

Changed

Improved (I)

Worsening (W)

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.    Number Residents with Facility Acquired Pressure Injuries: ______________________     % Residents with Facility Acquired Pressure Injury (A÷B) ________

 

B.    Total Number of All Residents in Census: _______________________

 

Wound Type Key:

1

Pressure Injury

2

Surgical

3

Venous Stasis

4

Arterial Ulcer

5

Skin Tear

6

Abrasion

7

Laceration

8

Diabetic Ulcer

9

Burn

10

Other

 

Pressure Injury Stages:  Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister.

                                                 Stage   1: Intact skin. Redness that DOES NOT BLANCH. Skin tones may appear red, maroon, blue, purple. Affected area may be warm, boggy or firm.

                                                 Stage   2: Skin is cracked, blistered, sheared or torn. Partial thickness wound. Does not heal with granulation.

                                 Stage 3: Broken skin, deep tissue involvement. Full thickness wound. Muscle, tendon, or bone is NOT visible.

                                 Stage 4: Broken through all layers of tissue. Full thickness wound. Muscle, tendon, or bone may be visible.

                                 Unstageable: Base of ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown, or black) in the wound bed.

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