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Wound 1
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Patient Conditions Affecting Healing:
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If advanced wound care started, document failed conservative care for 30 days prior to treatment:
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Specify which conservative treatments were tried and failed.
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Identify comorbid conditions:
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If Other, please describe
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Document adequate blood perfusion assessment (Capillary response, pulses, ABI)
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If the patient has diabetes, verify controlled diabetes status: (Hgb A1C and fasting BS, sensation testing)
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If the patient has VLU or arterial ulcers provide vascular/arterial assessment and document
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Response to conservative treatment if not on advanced wound care
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Medical Necessity for biologic wound cover/barrier
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Wound Description
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Wound Etiology/Cause:
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Wound Stage
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Partial-/Full-Thickness (Non-Pressure Wounds):
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Adherence of Tissue:
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Wound Bed Characteristics (select all):
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If Other, please describe
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Wound Exudate:
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If Other, please describe
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Exudate Amount:
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Wound Shape:
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Wound Edges:
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If Other, please describe
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Surrounding Tissue (Peri-wound):
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If Other, please describe
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Describe Wound Bed Color (%): Example 80% red, 0% yellow, and 20% black/brown
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Wound Odor:
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If Other, please describe
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Indicators of Infection:
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If yes, describe:
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Debridement
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Method of Debridement:
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If Other, please describe
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Necrotic Tissue Removed
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If yes, please describe the amount of devitalized tissue removed?
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Description of debridement:
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Picture before debridement
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Picture after debridement
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Pain:
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Patient is experiencing pain
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Pain at rest (Scale 1 - 10)
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Pain with movement (Scale 1 - 10)
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Pain at night (Scale 1 - 10)
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Provokes =
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Quality =
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Radiates =
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Severity =
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Time =
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Wound Measurement
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Length
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Width
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Depth
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Undermining/Tunneling:
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If yes, describe (clock method) (12 head to 6 toe):
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Length
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Width
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Wound Care Protocol
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Cleansed wound bed with
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If Other, please describe
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Topical Agents:
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If Other, please describe
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Primary Dressing applied (select all that apply))
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If Other, please describe
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Secondary Dressing applied (select all that apply))
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If Other, please describe
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Interventions to Promote Healing
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If Other, please describe
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Nutrition
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If Other, please describe
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Education & Training
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If Other, please describe
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Advanced Treatment
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Product Name
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Number of products used on specific wound
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Product Size
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Wastage (Reason & Amount)
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Lot Number
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Expiration Date
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Total Units Used
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Method of Application
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Patient Response
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