Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part One -- Diabetic Foot Ulcerations

Gerit Mulder, DPM, MS, David Armstrong, DPM, Susie Seaman, MSN, NP, CETN


Wounds. 2003;15(4) 

In This Article

Ulcer Assessment and Documentation

Complete ulcer examination and documentation of findings should be a part of every visit for patients with diabetic foot ulcers. Physical findings need to include information on location, shape, condition of wound bed, signs of infection, deterioration, and other characteristics listed on the sample forms in Figures 1A and B, 2A and B, and 3. Physical findings should be recorded at baseline and all subsequent visits and correlated to the extent of wound closure. Differential diagnoses should be established after physical findings have been noted. Assumptions should not be made that an ulcer is a diabetic foot ulcer without first ruling out other etiologies. In diabetic patients, these may include but are not limited to venous ulcers, ischemic ulcers, vasculitic ulcers, and malignancies.

Figure 1A.

This form is a sample of a patient visit record.

Figure 1B.

This form is a sample of a patient progress notes.

Figure 2A.

This form is a sample of initial patient evaluation.

Figure 2B.

Sample of an initial patient evaluation form, continued.

Figure 3.

this form is a sample of patient history.

Ulcer classification must be consistent and reproducible. Either the Wagner[27] or the University of Texas system[28] may be used. Regardless of which system is chosen, the key factors associated with poor outcome, depth, presence of infection, and presence of ischemia should be considered.

Once an ulcer has been thoroughly examined and the findings documented, a treatment plan may then be established. Patients with problems and requiring care determined to be out of the scope of the clinician treating the wound should be referred to the appropriate specialist.


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