NOTE: The instrument is copyright by Barbara Bates-Jensen.
Parameters (definitions and instructions for use are given in Figure 1 on page 24)
(1) size (length times width)
(2) depth
(3) edges
(4) undermining
(5) necrotic tissue type
(6) necrotic tissue amount
(7) exudate type
(8) exudate amount
(9) skin color surrounding wound
(10) peripheral tissue edema
(11) peripheral tissue induration
(12) granulation tissue
(13) epithelialization
Each item is scored from 1 to 5 points.
total score =
= SUM(points for all 13 parameters)
Interpretation:
• minimum score: 13 (although the scale on page 25 indicates that intact skin might be scored as 0)
• maximum score: 65
• The higher the score, the more severe the findings.
Performance:
• Inter-rater reliability: r = 0.96 to 0.99
• Test-retest reliability: r = 0.91 to 0.92
