PCP:

Date of service:

Resident/Attending:

Site:

DX:

Interval Hx:

Current treatment for the wound:

Change in the wound:

Drawing:

New study:

Assessment: (resolved, improved, stable, worse)

Treatment plan: Continue the current treatment? (yes, no)

Change in the treatment plan –

Follow-up in:   (days, weeks, months) with

Resident signature:________date / /  Attending signature:________/ /

Abbreviations: DX, diagnosis; Hx, history; PCP, primary care physician.