Form 2: Wound Assessment: Ulcer Information

On-Time Pressure Ulcer Healing Project

Describes new tools to document pressure ulcer healing and treatments as part of the On-Time Quality Improvement Program.
Patient ID:

Facility Name  _______________________________________

Date of Admission: __  __ /__  __ /__  __ __ __
                                    M  M      D    D    Y     Y   Y    Y

Resident ID: _____________________________________

Date Ulcer Identified: MM/DD/YYYY

Initial Stage:
(at time ulcer first identified)

I __  II ___  III ___  IV ___  
Unstageable ___

Multiple Ulcers ID Number

Multiple Ulcer ID: Ulcers will be uniquely identified for reporting. Use this section if you can answer 'yes' to 1 AND 2 below:
1. There are two or more ulcers on the same ulcer location and
2. Multiple ulcers on the same location were identified on the same date, e.g. same onset date

____

Condition:  
New ___ 
 Reopened ___
Occurrence:  
Admission ___ 
 In-House Acquired ___
Site of Ulcer:
Report DateM|M|D|DM|M|D|DM|M|D|DM|M|D|DM|M|D|DM|M|D|D
Report Type: Please select the report type: (Initial (I), Followup (F))IFIFIFIFIFIF
Ulcer Dimensions: (Enter ulcer length once; use method used at your facility, clock or longest aspect, and enter in appropriate space)
Length (clock method) cm.      
Length (longest aspect of the wound) cm.      
Width (perpendicular widest width of ulcer) cm.      
Depth cm.      
Wound Edges
1= Indistinct, diffuse, none clearly visible      
2= Distinct, outline clearly visible, attached, even with wound base      
3= Well-defined, not attached to wound base      
4= Well-defined, not attached to base, rolled under, thickened      
5= Well-defined, fibrotic, scarred, hyperkeratotic      
Undermining
Undermining Direction (O’clock)      
Undermining Length (cm.)      
1= Nonpresent      
2= Undermining < 2 cm in any area      
3= Undermining 2-4 cm involving < 50% wound margins      
4= Undermining 2-4 cm involving > 50% wound margins      
5= Undermining > 4 cm or tunneling in any area      
Tunneling
Tunneling Direction (O’clock)      
Tunneling Length (cm)      
Necrotic Tissue Type
1= None visible      
2= White/gray nonviable tissue &/or nonadherent yellow slough      
3= Loosely adherent yellow slough      
4= Adherent, soft, black eschar      
5= Firmly adherent, hard, black eschar      
Necrotic Tissue Amount
1= Nonvisible      
2= < 25 % of wound bed cover      
3= 25% - 50% wound covered      
4= >50% and < 75 % of wound covered      
5= 75% - 100% of wound covered      
Enter Necrotic tissue amount (enter % if 1-5 above not used at your facility)      
Drainage/exudate Type
1= None      
2= Bloody      
3= Serosanguineous: thin, watery, pale red/pink      
4= Serous: thin, watery, clear      
5= Purulent: thin or thick, opaque, tan/yellow, without odor      
6= Purulent: thin or thick, opaque, tan/yellow, with odor      
Drainage/exudate Amount
1= None, dry wound      
2= Scant, wound moist but no observable exudate      
3= Small      
4= Moderate      
5= Large      
Peripheral Wound Area
1= Pink or normal for ethnic group      
2= Bright red &/or blanches to touch      
3= White or gray pallor or hypopigmented      
4= Dark red or purple &/or nonblanchable      
5= Black or hyperpigmented      
Peripheral Wound edema
1= No swelling or edema      
2= Nonpitting edema extends < 4 cm around wound      
3= Nonpitting edema extends > or = 4 cm around wound      
4= Pitting edema extends < 4 cm around wound      
5= Crepitus and/or pitting edema extends > or = 4 cm around wound      
Peripheral Wound induration
1= Not present      
2= Induration < 2 cm around wound      
3= Induration 2-4 cm extending < 50% around wound      
4= Induration 2-4 cm extending > or = 50% around wound      
5= Induration > 4 cm in any area around wound      
Granulation
1= Skin intact or partial thickness wound      
2= Bright, beefy red; 75%-100% of wound filled &/or tissue overgrowth      
3= Bright, beefy red; < 75% and > 25% of wound filled      
4= Pink, &/or dull dusky red &/or fills < or = 25% of wound      
5= No granulation tissue present      
Enter Granulated Amt (enter % if 1-5 above not used at your facility      
Epithelialization
1= 100% wound covered, surface intact      
2= 75% to < 100% wound covered &/or epithelial tissue extends > 0.5 cm into wound bed      
3= 50% to < 75% wound covered &/or epithelial tissue extends to < 0.5 cm into wound bed      
4= 25% to < 50% wound covered      
5= < 25% wound covered      
Pain
Is the ulcer site painful? Select 0-10 on pain scale.      
Pain medication given for ulcer pain      

Return to Contents
Proceed to Next Section

Page last reviewed July 2009
Internet Citation: Form 2: Wound Assessment: Ulcer Information: On-Time Pressure Ulcer Healing Project. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcerhealing/waform2.html