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Complete the Wound Assessment (section 7)

Document all active wounds in section 7 of the Visit Wizard, capturing anatomy, measurements, tissue percentages by wound, precise anatomical location, exudate, pain, and photos needed for Medicare LCD compliance and longitudinal wound tracking.

Section 8 (Previous Treatment) is where ABI is documented — if you intend to order compression, enter the ankle-brachial index there. Missing ABI on a compression order now raises a soft warning rather than blocking you. See Visit Wizard overview.

Before you start

• You have completed steps 1–6 of the Visit Wizard for this encounter.
• You have a ruler or wound measurement tool available for length, width, and depth.
• A camera-enabled device is ready if photo upload is required by your facility protocol.

Steps

Open Wound Assessment

1. Reach step 7. Complete steps 1–6 in sequence. The step navigator highlights Wound Assessment when you arrive.

Step 7 opens with a list of wounds carried forward from the patient's chart. Click a wound to assess it or click Add Wound to document a new one.

2. Select the wound or add a new one. Click an existing wound to open its assessment form, or click Add Wound if this is a new wound.

Each wound carries a Treating / Monitoring status. Set a wound to Monitoring when you are watching it rather than actively treating it — it shows a yellow pill, relaxes some required fields for the visit, and stays Monitoring on the next visit's reload until you flip it back to Treating.

Complete the wound assessment form

3. Fill in identification and location fields.

Field	Details
Wound #	Auto-assigned; read-only for existing wounds
Anatomic Location	Editable, precise anatomic site (for example, Right lateral malleolus). The location field is editable per-wound.
Laterality	L (Left) · R (Right) · B (Bilateral)
Onset Date	Calendar picker
Duration (weeks)	Auto-calculated from Onset Date; editable

The top section of the wound assessment form. Required fields are marked with an asterisk.

The wound assessment form in its initial state, before fields are populated.

4. Select Etiology. Choose one value:

Value	Description
DFU	Diabetic Foot Ulcer
VLU	Venous Leg Ulcer
PU	Pressure Ulcer
Arterial	Arterial insufficiency ulcer
Mixed	Mixed arterial-venous etiology
Surgical	Post-surgical wound
Traumatic	Traumatic wound
Other	Other — requires free-text clarification

5. Select Stage / Classification. Choose the classification system appropriate to the wound type:

Value	Notes
Wagner scale	For diabetic foot ulcers (Wagner 0–5)
Stage I	Non-blanchable erythema of intact skin
Stage II	Partial thickness skin loss
Stage III	Full thickness skin loss
Stage IV	Full thickness tissue loss
Unstageable	Obscured base — cannot determine depth
DTI	Deep Tissue Injury — suspected

6. Enter measurements.

Field	Unit	Notes
Length (cm)	centimeters	Greatest dimension
Width (cm)	centimeters	Perpendicular to length
Depth (cm)	centimeters	Deepest point
Area cm²	square centimeters	Auto-calculated as Length × Width

Record Tunneling depth (cm) and direction, and Undermining using o'clock position and centimeters from the wound edge if present.

The mid-section of the form showing tunneling, undermining, periwound condition, wound edges, and pain scale.

7. Document tissue composition. The five fields must sum to exactly 100%.

Tissue Type	Field	Acceptable range
Granulation	Granulation %	0–100
Slough	Slough %	0–100
Necrotic	Necrotic %	0–100
Epithelial	Epithelial %	0–100
Eschar	Eschar %	0–100

Tissue composition entry. The running total indicator turns red if the sum exceeds or falls below 100%.

The Next button remains disabled until the five tissue percentages sum to exactly 100. Adjust each value until the total reads 100%.

8. Select Exudate Amount and Type.

Field	Options
Exudate Amount	None · Scant · Small · Moderate · Large · Copious
Exudate Type	Serous · Serosanguineous · Sanguineous · Purulent

9. Record Odor. Toggle Odor to Y or N.

10. Select Periwound condition.

    Value	Clinical meaning
    Intact	No periwound changes
    Macerated	Softening from prolonged moisture
    Erythematous	Redness around wound margins
    Callus	Hyperkeratotic periwound tissue
    Hyperpigmented	Post-inflammatory darkening

11. Select Wound Edges.

    Value
    Attached
    Epibole
    Rolled

12. Rate Pain. Drag the slider or type a number for Pain 0–10 (0 = no pain, 10 = worst imaginable pain).

13. Complete the Infection Signs checklist. Check all that apply from the infection indicators list (erythema, warmth, swelling, purulent drainage, malodor, increased pain, fever, lymphangitis, cellulitis). Leave unchecked if absent.

14. Upload a photo. Click Photo Upload, then select a photo from the device camera or library. At least one photo per wound per visit is recommended by most facility protocols.

    Many Medicare LCDs require photographic documentation at each visit for advanced biological therapy (graft) coverage. Confirm your facility's protocol and upload the photo before leaving the patient's location.

15. Click Save Wound. The wound record saves and you return to the wound list. Repeat steps 2–14 for each additional wound.

16. Click Next to advance to step 8, Previous Treatments, once all wounds are documented.

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Validation

If any required field is missing or tissue percentages do not sum to 100, the wizard displays inline validation errors.

Validation state: red outlines indicate fields that must be resolved before advancing.

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Result

Each wound has a saved assessment record with measurements, tissue composition, exudate, pain score, infection status, and at least one photo. On save, the LCD audit fires automatically and refreshes the LCD ambient badge — items like Dimensions measured today, Tissue percentages sum to 100, and Precise anatomical location flip from amber to green as soon as the data is on file.

If you document more than one wound, use the wound thumbnail strip at the top of step 7 to switch between wounds without losing your place in the form.

Troubleshooting

Symptom	Likely cause	What to do
Next button disabled	Tissue composition does not sum to 100%	Check the running total indicator and adjust percentages
Next button disabled	Required field missing	Scroll up — missing fields are outlined in red
Photo upload fails	File size exceeds 10 MB or unsupported format	Reduce image size or use JPEG/PNG format
Area cm² not updating	Length or Width field is empty	Enter both Length (cm) and Width (cm) values

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