Wound Solutions:
Stuart Edward Riggins
This is the Wound Solutions Patient Care Portal to submit patient information and referrals.
Initial 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:
- No elements found. Consider changing the search query.
- List is empty.
Constitutional | Denied*
- Change in Vital Signs
- Fever
- Weight-Loss
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Head | Reported*
- Dizziness
- Fainting
- Headache
- Head Trauma
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Head | Denied*
- Dizziness
- Fainting
- Headache
- Head Trauma
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
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:
- No elements found. Consider changing the search query.
- List is empty.
Respiratory | Denied*
- Asthma
- Bronchitis
- Shortness of Breath
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
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:
- No elements found. Consider changing the search query.
- List is empty.
Gastrointestinal | Reported*
- Abdominal Pain
- Chronic Constipation
- Decreased Appetite
- Heartburn
- Laxative Use
- N/A
- Other:
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- List is empty.
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:
- No elements found. Consider changing the search query.
- List is empty.
Psychiatric | Denied*
- Anxiety
- Behavioral Changes
- Disturbing Thoughts
- Insomnia
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Skin | Reported*
- Eczema
- Dryness
- Nail Appearance Change
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
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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- List is empty.
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:
- No elements found. Consider changing the search query.
- List is empty.
Endocrine | Denied*
- Cold Intolerance
- Fatigue
- Goiter
- Weakness
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Hematologic/Lymph | Reported*
- Anemia
- Lymphedema
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Hematologic/Lymph | Denied*
- Anemia
- Lymphedema
- N/A
- Other:
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- List is empty.
Allergic/Immunologic | Reported*
- Itchy Eyes
- Runny Nose
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Allergic/Immunologic | Denied*
- Itchy Eyes
- Runny Nose
- N/A
- Other:
- No elements found. Consider changing the search query.
- List is empty.
Vital Signs
BMI Calculator:
bmi.woundsolutionsusa.com
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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- List is empty.
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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- List is empty.
Tunneling | Minutes
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- N/A
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- List is empty.
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