How to Document a New Diabetic Foot Ulcer at the First Visit

When a patient like Pedro walks in with a month-old foot wound, the clinical clock is already running. This guide walks through the documentation workflow that turns a first-visit DFU encounter into an audit-ready chart without adding after-hours work.

Step 1: Capture the story before the exam

Ask when the wound appeared, what the patient has been putting on it, glycemic control, footwear, smoking status, and prior ulcers or amputations. Record it verbatim — an AI scribe for wound care can transcribe the intake so you keep your eyes on the foot.

Step 2: Image and measure before you debride

Use a phone-based AI-powered wound imaging capture to record length, width, depth, tissue composition, and periwound condition. Baseline images anchor every future comparison and satisfy payer expectations for objective measurement.

Step 3: Classify and grade

Assign a Wagner or University of Texas grade, note probe-to-bone status, pulses, and protective sensation. Document infection signs explicitly — erythema margins, odor, exudate character — because "looks infected" will not survive an audit.

Step 4: Offloading, orders, and follow-up

Order the offloading device, cultures if indicated, imaging for suspected osteomyelitis, and a return interval. The AI-powered EMR for wound care pulls the orders into the note so nothing falls between the visit and the front desk.

Step 5: Close the loop with the patient

Hand off wound-care instructions and confirm the patient understands the red flags. Between visits, Pingoo DFU coaching catches the questions that would otherwise turn into a missed appointment and a hospitalization.

See the full clinician workflow for diabetic foot care.