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Provider Care Plan
|
|
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Care Plan
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Follow Up
|
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Wound Care Goals
• • •
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Wound Care Goals Comment
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Concern for infection:
|
Concern for Infection Comment
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Antibiotic Initiated
|
Antibiotic Initiated Comment
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Reason for wound swab, if obtained:
|
Reason for Wound Swab Comment
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Supplementation Orders
• • •
|
Supplementation Orders Comment
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Other Medications Ordered
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Pharmacy, Date/Time Called In
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Grafting Medical Necessity
|
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Grafting Medical Necessity
|
|
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Patient has been diagnosed with
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Patient's comorbidities
• • •
|
|
Systemic disease related to the wound etiology are being managed by the patient's PCP and other specialists.
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Treatment of the underlying etiologies includes
• • •
|
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Previously Tried Treatments
• • •
|
|
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The wound is free of infection.
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Infection Comment
|
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Wound Bioburden Comment
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Interventions to address bioburden
• • •
|
|
The wound has adequate perfusion to support healing as evidenced by
• • •
|
Interventions to address vascularity
• • •
|
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Patient has sufficient nutritional status to support healing.
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Interventions to address nutrition include
• • •
|
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Medical Necessity Comments
|
|
|
Graft Placement
|
|
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Product Information
|
|
|
Graft 1 Product Info
|
|
|
Product Freewrite
|
|
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Biologic/Skin Substitute Brand
|
Biologic/Skin Substitute Brand Comment
|
|
Graft Application Site(s)
|
|
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Graft Units
|
Total Units Used
|
|
Total Units Wasted (IF APPLICABLE)
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Reason for Graft Waste (IF APPLICABLE)
|
|
Number of graft applications (including today's application)
|
Number of graft applications (including today's application) Comment
|
|
IVR #
|
|
|
Lot or ID #
|
Expiration Date
|
|
Graft 2 Product Info
|
|
|
Product Freewrite
|
|
|
Biologic/Skin Substitute Brand
|
Biologic/Skin Substitute Brand Comment
|
|
Graft Application Site(s)
|
|
|
Graft Units
|
Total Units Used
|
|
Total Units Wasted (IF APPLICABLE)
|
Reason for Graft Waste (IF APPLICABLE)
|
|
Number of graft applications (including today's application)
|
Number of graft applications (including today's application) Comment
|
|
IVR #
|
|
|
Lot or ID #
|
Expiration Date
|
|
Procedure
|
|
|
Procedure
|
|
|
Procedure Comments
|
|
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Patient Education
|
|
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Patient Education
|
|
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Tobacco Cessation Education
|
Tobacco Use Comment
|
|
Tobacco Use Status
|
|
|
Offloading Education
|
Offloading Wound Comment
|
|
Compression Education
|
Compression Education Comment
|
|
Nutrition/Protein Supplementation Education
|
Proper Nutrition Comment
|
|
BG Control Education
|
Glucose Management Comment
|
|
Fall Risk Education
|
Safe Transferring Comment
|
|
New Prescription Education
|
New Medication Prescribed
|
|
Education Freewrite
|
|
|
Wound Treatment Orders
|
|
|
Wound Treatment Orders
|
|
|
Wound Orders
|
|
|
Generic Substitutes Permitted
|
|
|
Dressing Change Frequency
• • •
|
HH to See Patient on
• • •
|
|
Innovation Medical to See Patient on
• • •
|
Next Innovation Appointment Date
|
|
Graft Instructions
• • •
|
Graft Instructions Comment
|
|
UltraMIST ordered?
|
UltraMIST Comment
|
|
UltraMist Order
|
|
|
Medical Equipment Order
• • •
|
Medical Equipment Order Comment
|
|
Lab Order
• • •
|
Lab Order Collection
|
|
Radiology Order
• • •
|
Radiology Order Comment
|
|
Referral
• • •
|
Referral Comment
|
