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Wound Assessment and Treatment
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Diabetic? // Pressure Ulcer?
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If diabetic, under medical management?
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The attending Primary Care Provider is ___.
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Most recent blood glucose level.
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Recent laboratory findings include an HbA1C result of ____
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Wound Description and Location
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The ulcer is located at ______
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categorized as ___
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It has been present since (month and year) ______
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Measurements in (cms) L W D
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There is [evidence/no evidence] of active infection or osteomyelitis,
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and [evidence/no evidence] of necrotic tissue.
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The patient also presents [with/without] an active Charcot deformity or major structural abnormality.
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There is [no/no known/suspected] malignancy associated with the ulcer.
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exposure of [Tendon/Muscle/Joint Capsule/Bone].
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Adequate Circulation with Diagnostic Testing:
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Recent diagnostic tests indicate an ABI result of _____
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on___________ [Date],
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pedal pulses [present/absent]
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on___________ [Date],
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TcPO2 with results ≥ 30 mmHG yielding ____________
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on___________ [Date],
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and Doppler arterial waveforms at the ankle ___
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on___________ [Date].
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Related Procedures and Conservative Treatment Measures:
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Debridement of necrotic tissue [was/was not] performed.
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Dressings [have been/ have not been] applied to maintain a moist wound environment.
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The patient [is/is not] on a non-weight-bearing regimen
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and [uses/does not use] pressure-reducing footwear.
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Standard compression therapy for venous stasis ulcers [is applied/is not applicable].
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Over the last 4 weeks, the patient [has/has not] adequately responded to conservative treatment measures.
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Currently, the patient [is/is not] undergoing HBOT.
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Their smoking status is [Smoker/Previous Smoker/Non-Smoker].
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They [have/have not] received counseling on smoking cessation.
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Additionally, the patient [is/is not] receiving radiation therapy or chemotherapy, taking medications considered immune system m
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The patient has a history of diabetes mellitus type 2 with peripheral neuropathy.
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Medical Necessity and Utilization Guidelines:
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Wound care services are medically necessary due to the presence of a chronic, non-healing wound that meets utilization guideline
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Wound measures [length x width x depth] cm after debridement.
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Pre-skin substitute application measurements are [length x width x depth] cm.
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Progress Monitoring
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Since the last application ____[duration] ago, there has been a slight reduction in wound size and improvement in wound bed gran
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Wound Bed Characteristics
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Wound Description
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Exudate
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Drainage Description
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Condition of Surrounding Skin
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Surrounding skin appears WNL without signs of infection.
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Indications of Infection
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No signs of infection noted; wound edges are clean and intact.
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Pain Description
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Pain Present/Description
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Product Usage: Skin Substitute
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Date
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Time
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Product Used
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Amount Used/Number of units
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Amount Wasted: _______________units
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Reason for wastage
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No product wastage noted during today's application.
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Wound Details
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After Debridement: [length x width x depth] cm.
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Pre-Skin Substitute Application: [__________ x __________ x _________] cm.
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2. Educate patient on proper wound care techniques at home.
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3. Follow-up appointment scheduled in ____[time frame] to reassess wound progress and adjust treatment plan as needed.
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