Wound Solutions:
Stuart Edward Riggins

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Graft Procedure

Graft Procedure

Patient Information

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Wound Assessment

Gender
Race
Language(s)
Social History | Living Circumstances
Social History | Tabacco History*
Social History | Tabacco Usage
Social History | Alcohol History*
Social History | Alcohol Usage
Social History | Drug History*
Social History | Drug Usage

Review of Systems

Constitutional | Reported
Constitutional | Denied
Head | Reported
Head | Denied
Eyes | Reported
Eyes | Denied
Respiratory | Reported
Respiratory | Denied
Cardiovascular | Reported
Cardiovascular | Denied
Gastrointestinal | Reported
Gastrointestinal | Denied
Musculoskeletal | Reported
Musculoskeletal | Denied
Psychiatric | Reported
Psychiatric | Denied
Skin | Reported
Skin | Denied
Neurological | Reported
Neurological | Denied
Endocrine | Reported
Endocrine | Denied
Hematologic/Lymph | Reported
Hematologic/Lymph | Denied
Allergic/Immunologic | Reported
Allergic/Immunologic | Denied

Vital Signs

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Extremity Pulses [Left/Right]
Extremity Pulses [Lower/Upper]
Extremity Pulses

Physical Exam

Skin & Wound Assessment

The following reports on the FIRST WOUND only, possible other wounds will be reported in a separated form.

Wound Base Percentage, Description*
Odor*
Drainage/Exudate | Quantity*
Drainage/Exudate | Type*
Peri-Wound Skin*
Wound Margins/Edges*
Undermining*
Tunneling*
Wound Type*
Wound Site Pain*
Wound Healing Phase*
Wound Classification*
Wound Classification | Wound Types*

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Diagnoses

Plan

Procedure Summary

Fill out the numbered bold parts in the fields below this paragraph.

The Graft recipient site was initially cleansed with [1] { } and a sterile 4 x 4 gauze for [2] {time}. Utilizing a [3] {mm} [4] {instrument} the entire wound bed was carefully scraped [5] { } care not to cut or excise the healthy connective tissue. Following the Procedure the entire Wound and Peri-wound Skin was cleansed with [6] { }. During the Procedure no bleeding or pain was reported.

Field 4 | Used Instrument*
Field 5 | With/Without*

Medical Necessity Statement

Fill out the numbered bold parts in the fields below this paragraph.

The Patient’s wound is approximately [1] { } [2] {weeks/months/years} old and healing has stalled, due to [3] { } and excessive inflammation and Biofilm presence. Wounds that are left open for long periods of time contain heavy bacterial contamination, and therefore need to be substantially prepped before application of the Amniotic Graft. Site preparation ensures achievement of optimal tissue environment, and promotes healing.

Field 2 | Weeks/Months/Years*

Application of Skin Substitute

Medical Necessity Statement

Fill out the numbered bold parts in the fields below this paragraph.

The Wound has not shown any substantial improvement with standardized Wound Treatments and therefore requires Advanced Wound Treatment options. This patient has a complex Medical history and has a high risk of developing further Medical complications associated with this chronic [1] { }. This patient meets all of the Medical eligibility criteria for the application of Human Amniotic Tissue.

Application of Multilayer Compression

Compression Pressure*

Fill out the numbered bold parts in the fields below this paragraph.

Multi-layer Compression Bandage was applied to the [1] { } [2] {extremity} from the [3] { } to the [4] { } to prevent pitting edema and copious drainage from the wound. The patient tolerated the procedure well.

Procedure Coding

Care Plan

Patient Education

Patient Education

Follow-Up Treatment

Follow Up Appointment*

Provider's Signature

Clear
Provider's Signature

Internal Note(s) for HQ | Not Included to Reporting

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