Patient Information
Patient Name
Date of Birth
Medical Record Number
Wound Information
Wound Location
Wound Type
Date of Onset
Wound Dimensions (L x W x D, cm)
Exudate Amount
Wound Appearance
Infection Signs
Erythema
Yes
No
Swelling
Yes
No
Warmth
Yes
No
Pain
Yes
No
Odor
Yes
No
Necrosis
Yes
No
Systemic Signs (e.g., Fever)
Yes
No
Microbiology
Date of Culture
Organisms Isolated
Antibiotic Sensitivity
Treatment
Current Treatment
Antibiotics Prescribed
Response to Treatment
Notes