HEALISTIC WC Patient Visit Doc.

HEALISTIC Wound Care Visit Form

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Date of Service

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Date
Hour MinutesAM/PM Option
Patient
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Tedder Physcian Order 3/9/26

Clease BLE wounds with DWC

Apply xlta to all wound beds and secure with wrap dressing

Change every Monday Wednesday and Friday
Mist Start Time

Hour Minutes
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- Photo
- Photo
- Photo

Samuel Physcian Order 3/20/26

#1-Lower Left Extremity

Cleanse LLE wound with DWC
Apply Omeza to wound bed; nickel thick. 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
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1- Left lateral ankle (8.4cm - 3 min)
- #2-Left heel (0.3 cm - 3 min)
- #1- Left lateral ankle
- #2-Left heel

Jones

Cleanse leg wounds x 3 with DWC
Apply a nickel thick layer of PHMB wound gel to wound and fill the dead space with collagen powder
Cover with xlta and secure with paper tape.
Change daily and prn soiling.
Mist Start Time

Hour Minutes
Gaskins (T/TH)
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1-Rt Midline Thigh - 3 min)
- #2-Rt Medial Thigh - 3 min)
- #3-Rt Lateral Thigh - 3 min)
- #1-Rt Midline Thigh - 3 min)
- #2-Rt Medial Thigh - 3 min)
- #3-Rt Lateral Thigh - 3 min)

Gaskins (M/W/F)

Cleanse BLE wounds with DWC
Apply collagen alginate to ALL wound beds and cover with Zetuvit Plus Super Absorbent
Secure with kerlix and elastic wrap
Change daily
Time

Hour Minutes
Type a question
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1-Rt Medial Lower Leg - 3 min)
- #2-Rt Medial Upper Leg - 3 min)
- #3-Rt Anterior Upper Leg - 4 min)
- #4-Rt Anterior Lower Leg - 3 min)
- #5-Rt Anterior Lateral Leg- 9 min)
- #1-Rt Medial Lower Leg - 3 min)
- #2-Rt Medial Upper Leg - 3 min)
- #3-Rt Anterior Upper Leg - 4 min)
- #4-Rt Anterior Lower Leg - 3 min)
- #5-Rt Anterior Lateral Leg- 9 min)

Gaskins (T-TH)

Cleanse BLE wounds with DWC
Apply collagen alginate to ALL wound beds and cover with Zetuvit Plus Super Absorbent
Secure with kerlix and elastic wrap
Change daily
Mist Start Time

Hour Minutes
Gaskins (T/TH)
WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1-Lt Lateral Leg - 5 min
- #2-Lt Lateral Leg - 11 min
- #3-Lt Lateral Leg - 3 min)
- #1-Lt Lateral Leg - 5 min
- #2-Lt Lateral Leg - 11 min
- #3-Lt Lateral Leg - 3 min)

Copelle

Cleanse BLE wounds with DWC
Apply collagen alginate to ALL wound beds and cover with Zetuvit Plus Super Absorbent
Secure with Unna boot compression therapy
HHN to change twice weekly
POST-TREATMENT WOUND PHOTOS

REMEMEBER: RULER WITH PATIENT NAME AND DATE
- #1 Rt dorsal foot - 3 min
- #2 Rt posterior ankle -3 min
- #3 Rt Posterior Leg-19 min
- #1 Lt Posterior leg-12 mins.
- #2 Lt medial ankle- 4 mins
- #3 Lt Heel- 3 mins
- #1 Rt dorsal foot - 3 min
- #2 Rt posterior ankle -3 min
- #3 Rt Posterior Leg-19 min
- #1 Lt Posterior leg-12 mins.
- #2 Lt medial ankle- 4 mins
- #3 Lt Heel-1 cm - 3 mins

VITALS
BP (mmHg)
Temp (°F)
Resp.(breaths/min)
O2 (%)
HR (bpm)
Measurments

Wound Measurements

Rows	Legnth	Width	Depth
Wound #1
Wound #2
Wound #3
Wound #4
Wound #5
Wound #6
Wound #7

VISIT CLOSURE
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