Wound Solutions:
Stuart Edward Riggins
This is the Wound Solutions Patient Care Portal to submit patient information and referrals.
Follow-Up Wound Assessment
Wound Assessment
Patient Information
Please make sure to enter the correct phone number. Entering incorrect phone numbers require resubmission of this entire reporting.
Wound Assessment
Gender
- Female
- Male
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Race
- American Indian and Alaska Native
- Asian
- Black or African American
- Hispanic
- Native Hawaiian and Other Pacific Islander
- White
- Two or more races
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Language(s)
- English
- Spanish
- Chinese (Mandarin)
- Chinese (Cantonese)
- Tagalog
- Vietnamese
- Arabic
- Other:
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Social History | Living Circumstances
- Living Alone
- Not Living Alone
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Social History | Tabacco History*
- Yes
- No
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Social History | Tabacco Usage
- Previous Tabacco User
- Current Tabacco User
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Social History | Alcohol History*
- Yes
- No
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Social History | Alcohol Usage
- Previous Alcohol User
- Current Alcohol User
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Social History | Drug History*
- Yes
- No
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Social History | Drug Usage
- Previous Drug User
- Current Drug User
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Review of Systems
Constitutional | Reported
- Change in Vital Signs
- Fever
- Weight-Loss
- N/A
- Other:
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Constitutional | Denied
- Change in Vital Signs
- Fever
- Weight-Loss
- N/A
- Other:
- No elements found. Consider changing the search query.
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Head | Reported
- Dizziness
- Fainting
- Headache
- Head Trauma
- N/A
- Other:
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Head | Denied
- Dizziness
- Fainting
- Headache
- Head Trauma
- N/A
- Other:
- No elements found. Consider changing the search query.
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Eyes | Reported
- Cataracts
- Glaucoma
- Unusual Sensations
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Eyes | Denied
- Cataracts
- Glaucoma
- Unusual Sensations
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Respiratory | Reported
- Asthma
- Bronchitis
- Shortness of Breath
- N/A
- Other:
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Respiratory | Denied
- Asthma
- Bronchitis
- Shortness of Breath
- N/A
- Other:
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Cardiovascular | Reported
- Chest Pain
- Hair-Loss on Legs
- Heart Attack
- Heart Surgery
- High Blood Pressure
- N/A
- Other:
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Cardiovascular | Denied
- Chest Pain
- Hair-Loss on Legs
- Heart Attack
- Heart Surgery
- High Blood Pressure
- N/A
- Other:
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Gastrointestinal | Reported
- Abdominal Pain
- Chronic Constipation
- Decreased Appetite
- Heartburn
- Laxative Use
- N/A
- Other:
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Gastrointestinal | Denied
- Abdominal Pain
- Chronic Constipation
- Decreased Appetite
- Heartburn
- Laxative Use
- Nausea
- N/A
- Other:
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Musculoskeletal | Reported
- Muscle Stiffness
- Joint Pain
- Joint Stiffness
- Restricted Motion
- Weakness
- N/A
- Other:
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Musculoskeletal | Denied
- Muscle Stiffness
- Joint Pain
- Joint Stiffness
- Restricted Motion
- Weakness
- N/A
- Other:
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Psychiatric | Reported
- Anxiety
- Behavioral Changes
- Disturbing Thoughts
- Insomnia
- N/A
- Other:
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Psychiatric | Denied
- Anxiety
- Behavioral Changes
- Disturbing Thoughts
- Insomnia
- N/A
- Other:
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Skin | Reported
- Eczema
- Dryness
- Nail Appearance Change
- N/A
- Other:
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Skin | Denied
- Eczema
- Dryness
- Nail Appearance Change
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Neurological | Reported
- Blackouts
- Dizziness
- Right-Sided Weakness
- Left-Sided Weakness
- Unsteady Gait
- N/A
- Other:
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Neurological | Denied
- Blackouts
- Dizziness
- Right-Sided Weakness
- Left-Sided Weakness
- Unsteady Gait
- N/A
- Other:
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Endocrine | Reported
- Cold Intolerance
- Fatigue
- Goiter
- Weakness
- N/A
- Other:
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- List is empty.
Endocrine | Denied
- Cold Intolerance
- Fatigue
- Goiter
- Weakness
- N/A
- Other:
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- List is empty.
Hematologic/Lymph | Reported
- Anemia
- Lymphedema
- N/A
- Other:
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Hematologic/Lymph | Denied
- Anemia
- Lymphedema
- N/A
- Other:
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Allergic/Immunologic | Reported
- Itchy Eyes
- Runny Nose
- N/A
- Other:
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Allergic/Immunologic | Denied
- Itchy Eyes
- Runny Nose
- N/A
- Other:
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Vital Signs
BMI Calculator:
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Extremity Pulses [Left/Right]
- Left
- Right
- Both Left & Right
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Extremity Pulses [Lower/Upper]
- Lower
- Upper
- Both Lower & Upper
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Extremity Pulses
- Normal Pulse
- Diminished Pulse
- Absent Pulse
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Physical Exam
Skin & Wound Assessment
The following reports on the FIRST WOUND only, possible other wounds will be reported in a separated form.
Etiology*
- Pressure Injury
- Venous Ulcer
- Arterial Ulcer
- Surgical Trauma
- Abrasion
- Burn
- Laceration
- Diabetic Ulcer
- Other:
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Skin Wound*
- None
- Partial Thickness
- Full Thickness
- Other:
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Pressure Injury Staging*
- None
- Stage I
- Stage II
- Stage III
- Stage IV
- Unstageable
- N/A
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% Non Pressure Wound Description*
- None
- Partial Thickness
- Full Thickness
- Other:
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Wound Bed Color*
- Red
- Pink
- Purple
- Black
- Yellow
- Brown
- Other:
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Undermining*
- Yes
- No
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Undermining | Hours
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- N/A
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Undermining | Minutes
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- N/A
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Tunneling*
- Yes
- No
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Tunneling | Hours
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- N/A
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Tunneling | Minutes
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- N/A
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Periwound*
- Indurated
- Erythema
- Macerated
- DTI
- Edema
- Hyperkeratotic
- Other:
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Exudate Type*
- Serosanguineous
- Purulent
- Fresh Blood
- Green Purulent
- Sanguineous
- Foul Purulent
- Serous Yellow
- Other:
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Exudate Amount*
- None
- Scant
- Small
- Moderate
- Large
- Copious
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Wound Odor*
- Yes
- No
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Wound Odor | Strength*
- Mild
- Strong
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Ship to*
- Home
- Office
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Upload Pictures
Diagnoses
Procedure Coding
Care Plan
Patient Education
Patient Education
- Importance of Diet in Wound Healing
- Off-loading and Pressure Ulcers
- Other:
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Provider's Signature
Internal Note(s) for HQ | Not Included to Reporting