• Complete questions 1 to 7 at a client's first visit to determine a baseline score.
• Two weeks later, the area of the client's ulcer will need to be entered to determine a two week score.
• A score will then be calculated by the app to indicate the risk of non-healing within 24 weeks.

Note: The baseline score and the baseline ulcer area will need to be recorded for the follow-up visit in two weeks.

Check medical records and confirm with client their age in years at time of completing the risk assessment tool.

Check medical records and confirm with client the duration that they have had this current ulcer for in weeks at the time of completing the risk assessment tool.

Check with client as to whether they live alone. Living alone does not include living with family members or living in an aged care facility.

Measure both a calf and ankle circumferences of the ulcerated leg, as per directions below. The app will calculate a calf/ankle ratio from these measurements.

Measuring calf and ankle circumferences

1. The client should be sitting with the leg hanging loosely or standing with their weight evenly distributed on both feet
2. Wrap the tape around the calf at the widest part and note the measurement
3. Wrap the tape around the ankle at the narrowest part and note the measurement
4. Take additional measurements above and below the points to ensure that the first measurement was the largest for the calf or smallest for the ankle
5. An accurate measurement can only be obtained if the tape is at a right angle to the length of the calf and ankle, and should be recorded to the nearest 0.1cm
6. 

Measuring bed-bound clients

1. Have the person being measured lie in a supine position with the knee bent at 90° angle.
2. Slip a loop of the tape measure around the calf until largest diameter is located
3. Slip a loop of the tape measure around the ankle until the smallest diameter is located
4. Pull tape so it is just snug but not so tight that tissue is compressed
5. Take additional measurements above and below the points to ensure that the first measurement was the largest for the calf or smallest for the ankle
6. Read and accurately record measurement to the nearest 0.1 cm.

Document tissue type, e.g:

Necrotic

Slough

Granulation

Epithelial

Calculate the ulcer area using the protocol or method of your organisation (e.g. calculate length x width).

Only numbers can be used.

The exact measurement of this area will need to be kept as this information will be needed to complete the risk assessment at the 2 week follow-up.

• The baseline score and baseline ulcer area from the baseline visit are required to complete the risk assessment.
• A score will then be calculated by the app to indicate the risk of non-healing within 24 weeks.

Calculate the ulcer area using the protocol or method of your organisation (e.g. calculate length x width).

Calculate the ulcer area using the protocol or method of your organisation (e.g. calculate length x width).

• Complete questions 1 to 6 within 4 weeks of healing of a venous leg ulcer, or at a client's first assessment after healing.
• The app will then calculate the total risk assessment score.

Confirm with client whether they have a history of leg ulcers.

Check with client as to whether they live alone. Living alone does not include living with family members or living in an aged care facility.

Ask the client - "Do you move around on your feet for at least 3 hours per day? - This could include times of walking, doing your house work or shopping". If they do not do this everyday, use an average of whether on most days they would do this.

Ask the client - "Do you elevate your legs for 30 minutes per day or more?" - This must be above the level of the heart.