Wound Treatment Order for :______(Facility Name)

(Use one form for each wound site)

Is this a Surgically Created Wound? (circle): Yes No

Has this Wound Been Debrided? (circle): Yes No Date of Debridement:______

If Yes, type of debridement (circle): autolytical chemical surgical mechanical

* * * * If you answered No to both of these questions, this wound is not billable to Medicare B* * * *

Directions: Please circle, check, or write in responses. Order Form Must Be Complete. See Form Instructions for help.

Section A

Resident Name:______Date of Order: (mm/dd/yy)______/______/______

Section B

Wound Site:______Number of Wounds at this Site (circle): 1 2 3

Diagnosis (ICD-9):  707.00 Decubitus  454.0 Venous  440.23 Arterial  250.80 Diabetic Ulcer (Type II) + 707.??

 Others: i.e. surgical (list ICD-9 code)______

Size of Wounds (L X W X D in cm): 1 ______2 ______3 ______

Stage of Wounds (circle): 1 II III IV eschar 2 II III IV eschar 3 II III IV eschar

Wound Type (circle): surgical decubitus stasis percutaneous catheter site

Section C

Tunneling present? (circle) Yes No

Drainage or exudate – Assess amount/type of drainage on dressing removed:

Amount (circle): none small moderate large Odor (circle): none foul sweet putrid

Section D

TREATMENT ORDER (All “Required” blanks must be complete. Incomplete orders will not be billed to Medicare.)

If you indicated multiple wounds for a single site, above, indicate total amounts used for all.

Primary Dressing______/ ______/ ______/

(Required)(Treatment – Fluff, Cover with, Pack with, Apply, etc.) (Quantity) (Size of Dressing)

______/ to: debride protect absorb hydrate

(Product Name) (Purpose of primary dressing: Circle all that apply)

Secondary DressingCover with ______/ ______/ ______/

(If Applicable) (Quantity) (Size of Dressing) (Product Name – TX over 1st Drsg) to: debride protect absorb hydrate (Purpose of 2nd dressing: Circle all that apply)

(If Applicable) Secure with ______/______/______/

(Quantity) (Size- L X W in inches for tape, pad size, # rolls) (Product Name)

(Required) Change ______/

(Frequency – daily, every other day, etc.)

Physician’s Name (printed) ______

Physician’s Signature:______Signature Date : (mm/dd/yy) ______/______/______

______Physician’s Signature N/A. Decrease in supply usage only. Order has not changed.

(Initial)

WOUND TREATMENT ORDER INSTRUCTIONS

General Information ALL BLANKS MUST BE COMPLETE. ONLY COMPLETE THIS FORM ON WOUNDS THAT HAVE BEEN DEBRIDED OR WERE SURGICALLY CREATED.

SECTION A

  1. Facility: Name of facility
  2. Resident Name: Include last, first, middle initial
  3. Wound debrided? : Debridement can be autolytic, enzymatic/chemical, mechanical (sharps) or autolytic. Refer to the chart that follows for a listing of the type of products that debride.

SECTION B

  1. Wound site: current wound treated site location.
  2. Diagnosis (ICD9 code): Check the box of current dx or fill in other type with code number.
  3. Number of wounds: The number of wounds at this site area treated by this same order. Note: Must have other treatment orders for different site areas.
  4. Size of wounds: Include length, width, depth in cm. (1cm x 2 cm x 0.5 cm)
  5. Stage of wound and comments: Decubitis ulcers are stageable I-IV, comment if wound unstageable and reason.
  6. Wound Type: Surgical, include type of surgery; decubitis, stasis or pressure related or percutaneous catheter site.

SECTION C

  1. Tunneling present: The wound has cavities present to be packed.
  2. Amount of exudates/drainage: small amount, moderate or large amount, the wound dressing to be appropriate with the type of drainage present.
  3. Odor: Is this wound infected, and would require more dressing changes?

SECTION D

Treament Order Information

  1. How to treat the wound: The wound is to be covered, packed, applied or fluff type dressing.
  2. Products Used: Include the product name, type, size and amount of each product to be used to treat the wound for each treatment. Specify whether the dressing is sterile or non-sterile if applicable. ( 1 Roll of 4” sterile Kling Fluff Rolls, or 1 2x 2 allevyn adhesive dressing)
  3. Purpose of Primary dressing: to debride, absorb, protect, hydrate. Circle all that apply to current wound order.
  4. Secondary Dressing: Dressing to apply over the wound and treatment, may not be applicable to all cases. ( Cover with (3) non-sterile 4 x 4 Gauze) Specify sterile or non-sterile.
  5. Secure dressing: Include the product name, amount in inches for length and width for each treatment change. (tape in inches; gauze in yards or rolls; transparent tape in pad size) Example: Hypafix tape 2 pieces of 2 in x 16 in.
  6. Change frequency of dressings: Times during the day the dressing change is performed on a routine basis.
  7. Physician: Ordering physician include first and last name. Physician must sign and date.

Exception: If new Wound Treatment Order form is only for a decrease in supply a new order is not required but

must be initialed by the treatment nurse or person submitting the form.

NOTE: ALL TREATMENT ORDERS FOR EACH WOUND MUST BE REWRITTEN EVERY 3 MONTHS.

Wound Care Product Performance Parameters by Categories

P – Primary performance parameter S – Secondary performance parameter DD – Dependent upon product form

Debridement
CATEGORY / Exudate Modulation / Hydration Maintenance / Protection / Autolysis / Enzymatic / Mechanical / Wound Healing
Alginate / P / S / S
Collagen / S / S / S / P
Composite / S / S / P
Compression: leg and wraps / P
Contact layer / P
Enzymes / P
Foam / P / S / P / S
Gauze / P / DD / DD / DD / DD
Growth Factors / DD / P
Hydrocolloid / P / S / S / S
Hydrofiber / P / S / S
Hydrogel / DD / P / S
Hydropolymers / P / S / P / S
Pouch / P / S / P
Sealants: skin and ointments / P
Skin cleanser / P
Specialty absorptives / P / S / S
Super-absorbents / P / S / S
Transparent film / S / P / P
Vacuum-assisted closure / P / S / S / S
Warming devices / P
Wound cleanser / P / S
Wound filler / S / S / S