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Demographics
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Facility / location
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POS 32 - LTC/Non-skilled/Domicile
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Rendering Provider
• • •
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Provider treating the patient’s systemic disease
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Review of pertinent medical problems: How treated / monitored. Reviewed at baseline visit?
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Change of patient medication since the Pre-Treatment visit
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Wound Description
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Ulcer Dimensions: (L cm x W cm x D cm) [Including Undermining]
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AREA: _________ SQ cm
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Full Thickness Ulcer
• • •
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Stage or Grade
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Wound Location
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Duration of the ulcer: _____ weeks
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Wound #1
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Wound #2
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Medical Necessity and Indications
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All conservative therapies previously used in the failed response of the current wound
• • •
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There has been no change to the following Factors of Non-Healing, from the Pre-Treatment visit
• • •
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Risk Factors:
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If diabetic ulcer, have identified presence of neuropathy?
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If venous insufficiency ulcer, have identified definitive presence of venous insufficiency?
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The patient’s arterial supply is sufficient. ABI >= 0.6 and/or TBI > 30mmHg?
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Hx of smoking?
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Is patient presently a smoker?
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If currently smoking, have smoking cessation counseling and cessation measures prescribed?
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Has smoking ceased during last 4 weeks?
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Informed Consent
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Factors present at exam:
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Select all that apply
• • •
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Graft Rationale
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Graft Size & Quantity Indicated
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Size of graft
• • •
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Additional graft
• • •
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Graft Application
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Date
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Time
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Op Note
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Op Note
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Post Procedure notes:
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Amount of graft used (%)
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Amount of graft discarded (%)
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Blood loss
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Hemostasis
• • •
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Anesthesia
• • •
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Stickers used
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Pain
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Premedication
• • •
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If Oral Pain Medicaton, specify
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Intra-operative _____/ 10
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Pre-operative _____/ 10
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Post-operative _____ / 10
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Patient Education
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LCD
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