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PRODUCT INFORMATION
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Product to be used for placement
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Partial or full thickness ulcer
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Sinus Tracts:
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Does wound have clean granular wound base:
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Is wound base clean and free of necrotic debris or slough:
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Is deficit at least 1.0 sq cm in size:
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Is there adequate circulation/oxygen to facilitate healing:
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Debridement of biofilm, no necrotic tissue or foreign body noted:
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What diagnostic tests have been completed:
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What were the results:
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History of tobacco use:
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Why has the wound failed to respond to conservative treatment:
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What specific interventions that have failed:
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Wound Information
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Wound Location:
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Type of wound
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Appropriate Therapy:
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Documentation of conditions that have been treated/resolved prior to the CTP therapy:
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Control of edema/venous hypertension or lymphedema:
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Has there been treatment of infection, bacteria or fungal colonization? What was the treatment?
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Has there been any elimination of underlying cellulitis, osteomyelitis, foreign body, or malignant process:
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Has there been appropriate debridement of necrotic tissue or foreign body (bone, tendon):
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Provision of wound environment to promote healing (protection from trauma/contaminants, elimination of inciting or aggravating processes):
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For venous stasis ulcers, compression therapy provided w/documented diligent use of multilayer dressings, compression stockings or greater than 20mmHg pressure, or pneumatic compression:
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Is wound a Diabetic foot ulcer:
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History of Diabetes:
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Is Diabetes well controlled:
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Does the medical record reflect a diagnosis of Type 1 or Type 2 Diabetes:
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Does the medical record reflect medical management of Diabetes:
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Date of last HbA1c:
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New Clinical Test & Result
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