Physician Reports – Mel LaFleur

Wound Type/Etiology (if known)Pressure ☐            Venous ☐               Arterial ☐                Diabetic ☐               Surgical 2°Intent X             Skin Tear ☐            Other ☐ If Pressure Ulcer, chart stage: Stage 1_________        Stage 2_________            Stage3_________         Stage 4_________                                       Stage X(unstageable)_________                   Stage SDTI (Suspected Deep Tissue Injury)_________                                                                                                                                                                                                                   MARK LOCATION OF WOUND/ULCER WITH AN ARROW OR AN ”X” Legend: X or Blank Space = Not Applicable (as per agency)    …