Review Podiatry Assessment – Outpatient
Purpose of Review:
Wound review for chronic plantar ulcer on the left foot, referred by the local community health centre for ongoing management and to assess healing progress following initial debridement.
Changes Since Last Assessment:
Patient reports reduced pain in the affected foot since the last assessment two weeks ago. The wound itself appears to be shrinking in size, and there are no new signs of infection reported. The patient has been compliant with offloading instructions and daily dressing changes as advised. No changes in footwear use.
Clinical Review Findings:
Wound on the plantar aspect of the left foot, distal to the metatarsal heads. Current wound dimensions are 1.5 cm x 1.0 cm x 0.2 cm (previously 2.0 cm x 1.5 cm x 0.3 cm). Wound bed is 70% granular with 30% slough, no signs of purulent discharge or foul odour. Peri-wound skin is intact, warm, and non-erythematous. Pedal pulses are palpable (dorsalis pedis and posterior tibial, 2+/4 bilateral). Capillary refill time is <3 seconds. No new callus or fissures observed. Nail health is stable. Gait remains antalgic but improved compared to previous visit.
Interventions Provided:
Gentle sharp debridement of remaining slough and hyperkeratotic wound edges. Application of a hydrocolloid dressing with secondary dressing for moisture balance and protection. Re-enforced pressure offloading education and technique, ensuring patient understands the importance of consistent adherence. Discussed optimal footwear choices for continued offloading and protection.
Client Progress Toward Goals:
Excellent progress toward the goal of wound healing, evidenced by a significant reduction in wound size and improved wound bed appearance. Pain reduction also indicates positive progress. Patient demonstrates good understanding and adherence to self-care instructions.
Updated Plan / Recommendations:
Rebook for follow-up review in 1 week (8 November 2024) to continue wound assessment and dressing changes. Continue hydrocolloid dressings and pressure offloading. Consider referral to an orthotist for custom accommodative inserts if current offloading measures are insufficient in the long term. Provide updated patient education on signs of infection to monitor at home.
Review Podiatry Assessment – Outpatient
Purpose of Review:
[describe reason for follow-up such as wound review, orthotic adjustment, diabetic foot monitoring, or pain management, as referred by local clinic, CHC, or hospital-based service]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Changes Since Last Assessment:
[outline any reported or observed changes in symptoms, foot function, use of footwear, or clinical presentation including wound deterioration or improvement]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Clinical Review Findings:
[update physical findings including wound size/appearance, signs of infection, presence of callus or fissures, nail health, pedal pulses, capillary refill, temperature changes, or changes in gait]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Interventions Provided:
[document any interventions such as sharp debridement, dressing application, prescription or adjustment of orthotics, provision of pressure offloading, or foot care education relevant to local public or private setting]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Client Progress Toward Goals:
[comment on client’s progress toward podiatric goals related to wound healing, mobility, pain reduction, footwear use, or self-care capacity]
(Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Updated Plan / Recommendations:
[document proposed follow-up management such as review schedule (e.g. rebook in 2/52), referral to community nursing for dressing changes, footwear order through state channels, or diabetic education referral]
(Only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own plan or recommendations.)
(Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)