TCP wound template

[date of consultation] (Write in the format DD/MM/YYYY. Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) Referrer: [referrer's name] (Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) GP: [GP's name] (Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) Re: [patient's name] (Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) Date of birth: [date of birth] (Write in the format DD/MM/YYYY. Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) Social History: [social history] (Patient's social situation, cognitive status, mobility, and consent for procedures. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Medical History: [medical history] (Patient's past and current medical diagnoses and relevant history. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Equipment: [equipment details] (Details of medical equipment in use for the patient, including wound dressings, pressure relief devices, and other aids. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Nutrition: [nutrition details] (Dietary recommendations and nutritional supplements prescribed or noted for the patient. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Medications: [medications] (Medication list review, reconciliation, specific medications noted, and their relevance to wound healing or other conditions. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Allergy: [allergies] (Patient's allergies. Write in full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) On Examination: *General Assessment:* [general assessment findings] (General physical assessment including patient's alertness, cooperation, perfusion, mucous membranes, sclera, conjunctiva, and absence of acute distress or infection signs. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) *Vascular:* [vascular assessment findings] (Vascular assessment findings including rubor, pallor, oedema, pedal pulses, patient reported symptoms, varicosities, skin condition, Doppler findings, ABPI attempts, and recommendations for further investigation or management. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Wounds: (Repeat the following format for each wound assessed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) *[wound location]:* [wound description] (Description of wound characteristics including type, margins, tissue, size, exudate, odour, and signs of infection or inflammation. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Impression: [clinical impression] (Overall clinical impression of the patient's condition, including wound diagnosis, uncertainty regarding aetiology, diagnostic requirements, and treatment recommendations. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Recommendations: [recommendations] (Detailed recommendations for conservative management, required dressings, antimicrobial management, follow-up, and surveillance. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Regime: [treatment regime] (Specific treatment regime including applications, coverings, frequency of dressing changes, and considerations for escalating treatment. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Final Opinion: [final opinion] (Final clinical opinion summarising initial classification, subsequent findings, adopted management approach, and plans for ongoing follow-up and monitoring. Write in paragraphs of full sentences. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)