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OM Skin Substitute
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OM Skin Substitute
OM Skin Substitute
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Patient Name
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First
Last
Patient DOB
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MM slash DD slash YYYY
Patient Sex (M/F)
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Male
Female
Date of Service
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MM slash DD slash YYYY
Market
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Arizona
California
Nevada
Utah
Texas
Florida
Wound Info
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The wound(s) has stalled or improved less than 50% despite greater than 30 days of traditional treatment. Will use a skin substitute graft to treat the wound and promote closure.
Post debridement the wound(s) are clean, have no signs of infection, and have a healthy granulating base.
A reasonable vascular supply is present based on (For lower extremity wounds only):
*
Not a lower extremity wound – continue to next section
Arterial Doppler Studies
ABI measurements
Physical Exam/History
Other:
Vascular Supply Other
Number of Skin Sub Treatments including today (e.g – if patient has no improvement after 4 treatments escalate per wound protocols):
*
Treatment consent
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The situation, risks, and benefits of the treatment were discussed in detail with the patient/family, and they agree with plans for treatment and is/are compliant with care.
Patients with Diabetes
For Patients with Diabetes
Not Diabetic – continue to next section
Patient’s most recent A1C is
Date of Lab
MM slash DD slash YYYY
Patients with Venous Ulcers
For Patients with Venous Ulcers
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Not a venous ulcer – continue to next section
Compression treatment has been utilized:
– Ace Wraps
– Compression Garments
– Tubigrips
– Coban Wraps
– Other
Venous Ulcer Other
Skin Substitute Treatment
Product Applied:
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Lot #:
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Serial #:
*
Expiration Date
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MM slash DD slash YYYY
Application Site:
*
Application Technique:
Skin substitute sized and trimmed to wound dimensions.
Graft applied directly to wound bed ensuring full contact.
Size of Graft:
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The amount of excess graft (sq cm) was discarded (if applicable)
Site Preparation:
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Skin Prep
Tincture of Benzoin
The graft was secured with:
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Steristrips
Tape
Xeroform
Petroleum Gauze
Oil Emulsion Gauze
Silicone Contact Layer
Transparent Film
Other:
Graft Secured Other
Secondary Dressing (if applicable):
Compression Applied:
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Yes
No
N/A
Offloading Implemented:
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Yes
No
N/A
Patient Response
Pain During Treatment:
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0
1
2
3
4
5
6
7
8
9
10
Patient Tolerance:
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Well tolerated
Poorly tolerated
Intervention provided
Post-Procedure Pain Level:
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0
1
2
3
4
5
6
7
8
9
10
Observed Changes:
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Improved epithelial tissue
Reduction in wound size
Total wound closure
No complications observed
No increased pain, bleeding, rash or other concerns
Other:
Observed Changes Other:
Follow Up Plan
Follow Up Plan:
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Patient/caregiver educated, advised and agreed with the following:
Do not remove dressing until next Woundtech Provider visit.
Keep dressing clean, dry and intact. Protect from water.
Wound care and offloading.
Monitor for signs of infection or graft rejection.
Call Woundtech provider for: Increased pain, bleeding, rash, other concerns.
Rerun visit in (days/weeks for reassessment and/or repeat skin substitute application)
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Provider Name:
*
Provider NPI:
*
Provider Signature:
*
Date
*
MM slash DD slash YYYY
Time
*
Hours
:
Minutes
AM
PM
AM/PM
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