Wound Clerking Template

Complete the patient details and wound background.
Add every wound site, then document the examination findings for each site.
Record red flags, wound status, relevant risk factors, and the management plan.
Select Generate Clerking Summary to prepare the clinical note.
Select Generate Referral Letter when a referral is required, then review the letter before printing.

Patient name

Age

Sex

Smoking status

Complete the basic details first: site, duration, cause and progression.

Site of wound

Specific site

Duration

Cause details

Progression

Improving Static / no improvement Worsening Increasing in size Recurrent at same site

Pain severity

Pain trend

Fever / systemic symptoms

Discharge amount

Discharge type

Odour

If diabetic: latest RBS / HbA1c

Current diabetic treatment

Previous treatment / dressing history

No previous treatment Dressing at KK Dressing at hospital Self-dressing Traditional medication Antibiotic completed Currently on antibiotic Previous wound swab Previous debridement

General condition

Temperature

Vital signs

Length, cm

Width, cm

Depth, cm

Wound bed

Red granulation Pink epithelialising Yellow slough Black necrotic tissue Pale wound bed Hypergranulation Exposed tendon Exposed bone Foreign body seen

Wound edge

Exudate amount

Exudate type

Undermining / tunnelling

Buka bahagian ini jika wound berada di foot, toe, hand, lower limb atau upper limb.

Limb temperature

Limb colour

Capillary refill time

Dorsalis pedis pulse

Posterior tibial pulse

Sensation

Movement

Healthy wound features

Red granulation Pink epithelialisation Size reducing Minimal serous exudate No foul smell No surrounding cellulitis

Healthy wound features identified.

Unhealthy or delayed healing features identified. Consider review of dressing method, risk factors and need for doctor review.

Symptoms of wound infection identified. Assess severity, systemic symptoms and need for antibiotics / referral.

Impression

Other impression / comments

Follow-up / dressing appointment

Referral details

Safety netting

Fever Redness spreading Pain worsening Discharge increasing Foul smell Wound becoming black Foot cold / pale Reduced movement / sensation

Referring clinic

Referring doctor

Reason for referral

Click “Generate Referral Letter” to create the letter.