Progress Note (Skin and Wound) v1.0

REASON FOR REASSESSMENT: 
[text name="variable_1" default=""]

CONTACT TYPE:
[text name="variable_2" default=""]

[checkbox name="variable_1" value="Informed consent was obtained to provide virtual care and communicate using electronic means, understanding that interception is possible. The patient understands that a complete physical exam is not possible virtually. The patient knows to seek urgent in-person medical attention should the need arise."]

INTERVAL HISTORY: 
[textarea name="variable_1" default=""]

SYSTEMS REVIEW: 
[textarea name="variable_2" default=""]

VITAL SIGNS: 
[checkbox name="variable_2" value="Deferred"]
Temperature:
[text name="variable_20" default="_ degrees celsius"]
Blood pressure:
[text name="variable_21" default="/"]
Pulse:[text name="variable_1" default="_ beats per minute"]
Respiratory rate:
[text name="variable_22" default="_ breaths per minute"]
Oxygen saturation:
[text name="variable_23" default="_% on ambient air/_ Liters per minute"]

PHYSICAL EXAMINATION
General: Aware, alert, oriented, and non-toxic appearing.
Cardiovascular: S1,S2, no additional heart sounds, jugular venous pulse not distended, no CIED generator/no CIED generator site tenderness, erythema, tenderness, or fluctuance.
Respiratory: Adequate air entry, clear to auscultation bilaterally, no adventitious sounds, no central cyanosis, no peripheral cyanosis, no obvious respiratory distress.
Abdominal: Soft and non-tender, no voluntary or involuntary guarding or rigidity, no ascites by fluid wave or shifting dullness, no jaundice or icterus.
Neurological: No meningeal signs, no cranial nerve deficits, no extraocular movement deficits.
Integumentary: No rash or petechiae, no wounds, or other dermal defects.

Erythema? [checkbox name="variable_160" value="Yes|No"]
If yes, describe the location:
[text name="variable_24" default=""]

Rash? [checkbox name="variable_161" value="Yes|No"]
If yes, describe the location:
[text name="variable_25" default=""]
If yes, describe the character: [checkbox name="variable_162" value="Macular|Papular|Pustular|Vesicular|Bullous|Psoriatic|Eczematous"]
Wound(s)? [checkbox name="variable_163" value="Yes|No"]
Number:
[text name="variable_26" default=""]
Location:
[text name="variable_27" default=""]
Length:
[text name="variable_28" default="cm"]
Width:
[text name="variable_29" default="cm"]
Depth:
[text name="variable_30" default="cm"]

If yes, describe the wound edge:
[checkbox name="variable_164" value="Attached|Unattached|Rolled/Epibolic|Hyperkeratotic|Undermined"]
If yes, describe the base:
[checkbox name="variable_165" value="Granular|Hypergranular|Sloughy/Necrotic|Eschar|Not visible"]
If yes, Describe the percentage of each:
Granulation tissue:
[text name="variable_31" default="%"]
Slough:
[text name="variable_32" default="%"]
Necrotic tissue:
[text name="variable_33" default="%"]

If yes, is there exudate? [checkbox name="variable_166" value="Yes|No"]
If yes, describe the character:
[checkbox name="variable_167" value="Serous|Sanguineous|Purulent|Blue|Green|Odourous"]
If yes, describe the volume:
[checkbox name="variable_168" value="Small|Moderate|Large"]
If yes, is there tunneling? [checkbox name="variable_169" value="Yes|No"]
If yes, describe the depth:[text name="variable_34" default="cm"]
If yes, describe the position:
[text name="variable_35" default="O'clock"]
If yes, describe the periwound:
[checkbox name="variable_170" value="Macerated (MASD)|Friable|Erythematous|Edematous|Dry/flaky|Dermatitic|Serous Crust|Exfoliative"]
Odour? [checkbox name="variable_171" value="Yes|No"]

Vascular assessment:
[checkbox name="variable_172" value="Right dorsalis pedis pulse palpable|Left dorsalis pedis pulse palpable|Dorsalis pedis pulses palpable bilaterally|Right posterior tibial pulse palpable|Left posterior tibial pulse palpable|Posterior tibial pulses palpable bilaterally|Right Dorsalis pedis pulse audible by handheld doppler|Left dorsalis pedis pulses audible by handheld doppler|Dorsalis pedis pulses audible by handheld doppler bilaterally|Right posterior tibial pulse audible by handheld doppler|Left posterior tibial pulse audible by handheld doppler|Posterior tibial pulses audible by handheld doppler"]
Waveforms:
[checkbox name="variable_173" value="Monophasic|Biphasic|Triphasic"]

LABORATORY DATA/IMAGING

Microbiology:
[textarea name="variable_18" default="Peripheral blood cultures x 2 sets on :
Line cultures x 2 sets on _:
Urine culture on _:
Sputum culture on _:
Device culture on: _"]

Hematology:
[textarea name="variable_19" default=""]
Chemistry:
[textarea name="variable_20" default=""]
Inflammatory markers:
[textarea name="variable_21" default=""]
Pathology:
[textarea name="variable_22" default=""]

X-ray imaging:
[checkbox name="variable_174" value="N/A"]
[textarea name="variable_23" default=""]


CT imaging:
[checkbox name="variable_175" value="N/A"]
[textarea name="variable_24" default="Head on _:
Soft tissues of the neck on _:
CTA Head and nekc on_:
Chest on _:
Abdomen/pelvis on _:
Lumbar spine on _:
Thoracic spine on _:
Cervical spine on _:
CT angiogram of the lower extremities on _:"]

MRI: [checkbox name="variable_176" value="N/A"]
[textarea name="variable_25" default="Head on _:
Lumbar spine on _:"]


Ultrasound: [checkbox name="variable_177" value="N/A"]
[textarea name="variable_26" default="Abdomen on _:"]


Echocardiogram: [checkbox name="variable_178" value="N/A|Transthoracic|Transesophageal"]
[textarea name="variable_27" default="Transthoracic on _:
Transesophageal on _:
Aortic valve:
Mitral valve:
Tricuspid valve:
Pulmonic valve:
Lead:"]

PROCEDURE: [checkbox name="variable_179" value="Deferred"]
Pre-procedural diagnosis:
[text name="variable_36" default=""]
Post-procedural diagnosis:
[text name="variable_37" default=""]
Procedure performed:
[checkbox name="variable_180" value="Conservative sharp debridement|Debridement of open soft tissue penetrating to bone|Dermal punch biopsy|Bone biopsy"]
Start:
[text name="variable_38" default="_ am/pm"]
End:
[text name="variable_39" default="_ am/pm"]
Procedural details: The patient was advised of the risk of pain, bleeding, soft tissue injury, and the possibility of infection leading to severe complications including tissue and limb loss. The patient was also advised of the mitigating strategies. Once satisfied, the patient provided informed verbal consent to proceed.

The area was cleansed with:
[checkbox name="variable_181" value="10% povidone-iodine solution|2% Chlorhexidine gluconate solution|0.9% saline"]
The area was draped in the usual fashion:
Using a:
[checkbox name="variable_182" value="Sterile, single-use 5mm dermal curette|Sterile, single-use 3mm dermal curette|#15 blade|Adson's toothed forceps|Bone rongeur"]
I was able to debride the:
[checkbox name="variable_183" value="Non-viable tissue|Hyperkeratotic tissue|Necrotic tissue"]
In the:
[checkbox name="variable_184" value="Wound edge|Wound bed"]
This was brought down to healthy bleeding tissue. Subsequently hemostasis was achieved with:
[checkbox name="variable_185" value="Direct pressure|Silver nitrate|Monsel's solution"]
Subsequently an antimicrobial dressing was applied.

The procedure was tolerated well
[checkbox name="variable_186" value="Without the use of topical anaesthetic reflecting profound sensory loss|with the use of 2% lidocaine infiltrated into the wound edge and base"]
Complications:
[checkbox name="variable_187" value="Nil"]
[textarea name="variable_28" default=""]

Estimated blood loss:
[text name="variable_40" default="_CCs"].

ANALYSIS/PLAN
[textarea name="variable_29" default="1.
2.
3.
4.
5.

Wound Dressings:
Compress/Soak:
Primary:
Secondary:
Compression:
Frequency:
"]
REASON FOR REASSESSMENT:


CONTACT TYPE:




INTERVAL HISTORY:


SYSTEMS REVIEW:


VITAL SIGNS:

Temperature:

Blood pressure:

Pulse:
Respiratory rate:

Oxygen saturation:


PHYSICAL EXAMINATION
General: Aware, alert, oriented, and non-toxic appearing.
Cardiovascular: S1,S2, no additional heart sounds, jugular venous pulse not distended, no CIED generator/no CIED generator site tenderness, erythema, tenderness, or fluctuance.
Respiratory: Adequate air entry, clear to auscultation bilaterally, no adventitious sounds, no central cyanosis, no peripheral cyanosis, no obvious respiratory distress.
Abdominal: Soft and non-tender, no voluntary or involuntary guarding or rigidity, no ascites by fluid wave or shifting dullness, no jaundice or icterus.
Neurological: No meningeal signs, no cranial nerve deficits, no extraocular movement deficits.
Integumentary: No rash or petechiae, no wounds, or other dermal defects.

Erythema?
If yes, describe the location:


Rash?
If yes, describe the location:

If yes, describe the character:
Wound(s)?
Number:

Location:

Length:

Width:

Depth:


If yes, describe the wound edge:

If yes, describe the base:

If yes, Describe the percentage of each:
Granulation tissue:

Slough:

Necrotic tissue:


If yes, is there exudate?
If yes, describe the character:

If yes, describe the volume:

If yes, is there tunneling?
If yes, describe the depth:
If yes, describe the position:

If yes, describe the periwound:

Odour?

Vascular assessment:

Waveforms:


LABORATORY DATA/IMAGING

Microbiology:


Hematology:

Chemistry:

Inflammatory markers:

Pathology:


X-ray imaging:




CT imaging:



MRI:



Ultrasound:



Echocardiogram:


PROCEDURE:
Pre-procedural diagnosis:

Post-procedural diagnosis:

Procedure performed:

Start:

End:

Procedural details: The patient was advised of the risk of pain, bleeding, soft tissue injury, and the possibility of infection leading to severe complications including tissue and limb loss. The patient was also advised of the mitigating strategies. Once satisfied, the patient provided informed verbal consent to proceed.

The area was cleansed with:

The area was draped in the usual fashion:
Using a:

I was able to debride the:

In the:

This was brought down to healthy bleeding tissue. Subsequently hemostasis was achieved with:

Subsequently an antimicrobial dressing was applied.

The procedure was tolerated well

Complications:



Estimated blood loss:
.

ANALYSIS/PLAN

Result - Copy and paste this output:

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