Wound Assessment

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Braden Score and Risk SENSORY PERCEPTION: MOISTURE: ACTIVITY: MOBILITY: NUTRITION: FRICTION & SHEAR: Total Braden Score: Braden Score: Braden Risk: Advanced to next level of risk due to other major risk factors?

Pain, Exudate, and Odor Is the patient experiencing wound pain? If Yes, Pain Intensity (1-10): Pain Type: Pain Frequency: Pain Treatment: Exudate Amount: Exudate Consistency: Odor (after cleansing):

Infection / Colonization Wound Edges: Periwound Tissue: Signs of Local Infection (NERDS):
Non-healing Exudate↑ Red/Friable Tissue Debris Smell
Signs of Systemic Infection (STONEES):
Size↑ Temperature↑ Osteomyelitis New Breakdown Pain↑ Erythema/Edema Smell/Odor

Wound Healing Status Wound Classification: Clinical Course:

Wound Location and Measurements Wound Location (Anatomical Description): Length (cm): Width (cm): Depth (cm): Reason If Unable to Determine Depth: Undermining (cm) and Clock Location: Tunneling (cm) and Clock Location:

Vascular Testing and Labs Pedal Pulses: Dorsalis Pedis - Present Posterior Tibialis - Present Diminished Absent Capillary Refill: ABI (Ankle Brachial Index): Venous Filling Time (sec): Rubor of Dependency: Lab Tests Ordered:
CBC Hemoglobin A1c Blood Glucose Albumin Prealbumin Coagulation Studies CRP Procalcitonin Wound Culture Microbial DNA

Treatment Plan and Dressing Protocol Wound Cleanser: Dressing Protocol:
Hydrogel Hydrofiber Calcium Alginate Foam Dressing Gauze Wrap Adhesive Tape Transparent Film Silver-Impregnated Other
Pressure Redistribution Devices: Low Air Loss Mattress Heel Offloading Boots Wedge Cushion Medications Used (e.g., Topical/Oral): Nutritional Support: Referral Recommendations: Vascular consult Skin Graft Nutrition consult Infectious disease PT / OT / SLP Podiatry Mental Health Follow-Up Frequency:

Debridement Documentation Debridement Performed? Type of Debridement: Pre-Debridement Dimensions (L x W x D in cm): Post-Debridement Dimensions (L x W x D in cm): Depth of Debridement: Instruments Used:
Scalpel Curette Forceps Scissors
Topical Anesthetic Used? Estimated Blood Loss (if any): Debridement Summary:

Patient Education Education Topics Covered:
Wound care instructions
Signs of infection
Pressure relief and repositioning
Proper nutrition for healing
Blood sugar management
Importance of follow-up
Patient's Understanding: Additional Comments:

Billing Codes and Units Surgical Debridement CPT Code(s):
11042 - Subq, first 20 cm²
11045 - Subq, each additional 20 cm²

11043 - Muscle/fascia, first 20 cm²
11046 - Muscle/fascia, each additional 20 cm²

11044 - Bone, first 20 cm²
11047 - Bone, each additional 20 cm²

Home Visit CPT Code: Office Visit CPT Code: Telehealth/Audio Visit Code: Assisted Living Facility Visit CPT: Additional Units for Surgical Debridement (11045, 11046, 11047): Active Wound Care Management CPT:
97597 - Active wound care
97598 - Each add’l 15 min
Number of Units:

Diagnosis - ICD-10 Wound Diagnosis (ICD-10) - Select all that apply:
L97.101 - Non-pressure ulcer, right thigh, skin breakdown
L97.102 - Right thigh, fat layer exposed
L97.103 - Right thigh, necrosis of muscle
L97.104 - Right thigh, necrosis of bone
L89.152 - Sacral pressure ulcer, stage 2
L89.153 - Sacral pressure ulcer, stage 3
L89.154 - Sacral pressure ulcer, stage 4
E11.621 - Type 2 diabetes with foot ulcer
I87.2 - Venous insufficiency (chronic)
I83.813 - Varicose veins with ulcer
R26.2 - Difficulty in walking
Z46.89 - Device fitting/adjustment
Z48.817 - Surgical aftercare, skin
Additional ICD-10 Notes / Custom Diagnoses:

$1 Clinician Name: Date: Draw Signature Below: