Wound VAC Application Checklist Form
Complete this checklist to document wound VAC application readiness and setup. Ensure all steps are verified before submission.
Patient Initials
*
Patient Room Number
*
Date of Application
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Wound Location
*
Please Select
Abdomen
Leg
Arm
Back
Other
Wound Type
*
Please Select
Surgical
Traumatic
Pressure Ulcer
Diabetic Ulcer
Other
Supplies and Equipment Ready
*
Dressing kit available
VAC device available
Canister installed
Tubing prepared
Dressing Applied and Sealed
*
Yes
No
VAC Device Settings Checked
*
Pressure set as ordered
Mode set (continuous/intermittent)
Alarms tested
Troubleshooting/Status Notes
Staff Name Completing Checklist
*
Submit Checklist
Should be Empty: