AYP & HEAL WC Patient Visit Doc.

Wound Care Visit Form

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Date of Service*

MonthDayYear
Date
Time In*

Hour Minutes

AM/PM Option
Organization

AYP Mobile WCHealistic WC Group
Patient*
Select a patient to view and record medical details, vital signs, and treatment images.
Patient*
Select a patient to view and record medical details, vital signs, and treatment images.

Samuel Physcian Order 3/20/26

#1-Lower Left Extremity

Cleanse LLE wound with DWC
Apply Omeza to wound bed. Cover with a dry dressing. Change every MWF
Keep LLE and heel floated off wheelchair and bed.

#2-Left Heel

Cleanse L heel wound with DWC
Apply Omeza to wound bed; nickel thick.
Cover with dry dressing
Change once daily
Mist Start Time

Hour Minutes
#1-Left lateral ankle (10 cm - 4 min)#2-Left heel (1 cm - 3 min)
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1- Left lateral ankle (10 cm - 4 min)
- #2-Left heel (1 cm - 3 min)
- #1- Left lateral ankle
- #2-Left heel

Jordan

Referal to Dr Piccolo Appt.: 3/31 @ 2 PM

Cleanse left foot wounds with DWC
Cut to fit calcium alginate dressing and apply to wound bed
Cover with dry dressing and secure with wrap dressing

Do not soak feet

Non weight bearing to left foot

Referred to Dr Piccolo 3/31 @ 2 PM

HH Pruitt - Heidi
Jordan

#1 Left lateral foot (0.25 cm-3 min)#2 Left plantar foot (2.25 cm-3 min)
POST-TREATMENT WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1 Left lateral foot (0.25 cm-3 min)
- #2 Left plantar foot (2.25 cm-3 min)
- #1 Left lateral foot
- #2 Left plantar foot

McRoberts

Cleanse LLE wounds with DWC
Cut to fit polymem foam and cover wounds
Wrap with Kerlix and secure with tape
Change every other day

Amedysis-Lisa-330-421-1470
Mist Start Time

Hour Minutes
McRoberts

#1 Left Medial Lower Leg (0.75 cm-3 min)#2 Left Anterior Lower Leg (0.6 cm-3 min.)
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1 Left Medial Lower Leg (0.75 cm-3 min)
- #2 Left Anterior Lower Leg (0.5 cm-3 min.)
- #1 Left Medial Lower Leg
- #2 Left Anterior Lower Leg

Phillips

Cleanse right plantar heel wound with DWC. Apply a allyvn adhesive dressing. Change every other day and as needed for soiling.
Phillips

#1-Right Plantar Heel (2 cm- 3 min)
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1-Right Plantar Heel
- #1-Right Plantar Heel

Vandroff (M-W)

Cleanse Right lateral heel wound, Right mid foot wound with DWC. Loosely pack all wound beds with dakin's moist MESALT. Cover with ABD pad and secure with tape.

ROHO cushion for wheelchair

Low air loss surface to bed
Time

Hour Minutes
Type a question

#1-Right lateral heel (6 cm - 3 min)#2-Right mid foot (0.9 cm - 3 min)
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1-Right lateral heel (6 cm - 3 min)
- #2-Right mid foot (0.9 cm - 3 min)
- #1-Right lateral heel
- #2-Right mid foot

Vandroff (T-TH)

Cleanse sacral wound, Right trochanter wound, Right ischial wound with DWC. Loosely pack all wound beds with dakin's moist MESALT. Cover with ABD pad and secure with tape.

ROHO cushion for wheelchair

Low air loss surface to bed
Mist Start Time

Hour Minutes
Vandroff

#1-Sacrum (48 cm - 7 min)#2-Right Trochanter (18 cm - 4 min)#3-Right Ischium (22 cm - 5 min)
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1-Sacrum (48 cm - 7 min)
- #2-Right Trochanter (18 cm - 4 min)
- #3-Ishium (22 cm - 5 min)
- #1-Sacrum
- #2-Right Trochanter
- #3-Ishium

Wade

Cleanse midline abdominal wound with DWC. Apply a thin layer of collagen poweder to wound bed. Fill dead space with alginate dressing. Cover with ABD and secure with tape. Change daily
Wade

1-Midline Abdomen (16.5 cm - 4 min)
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1-Midline Abdomen (16.5 cm - 4 min)
- #1-Midline Abdomen

VISIT CLOSURE
Documented during today's visit

Pre-treatment photo(s)Post-treatment photo(s)Measurements (Wednesday)Wound(s) Closed (document in not section)
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Notes
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Wound Care Visit Form