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Wound Care Orders

This information is now required for Medicare's reimbursement of the ordered supplies. Feel free to print and use the following sheet to order wound care on your patients.

Patient's Name:

Date: 

Doctor's Name: 

Doctor's Phone Numbers: 

Doctor's Fax Number: 

Location of Wound: 

Product ordered (circle):

Alginate cover, Alginate filler, Composite dressing, Foam dressing, Foam filler, Gauze non-impregnated, Gauze impregnated (other than water or normal saline), Hydrocolloid cover and filler, Hydrogel wound cover, Hydrogel wound filler, Specialty absorptive dressing, Transparent film, other wound filler, wound pouch, tape, elastic bandage, elastic gauze, non-elastic gauze

Name of product:

Product size: 

Number of dressings to be used at each dressing change (if more than one):

Frequency of Dressing Changes: 

Expected duration of need:

How many days should these orders be followed? 

Circle and / or fill in the following information if you would like it followed.

  1. Cleanse the wound with either saline or dermal wound cleanser for 5 minutes.
  2. Measure the wound, stage the wound, assess granular and necrotic tissue
  3. Apply ________________ to the base of the wound.
  4. Apply ________________ to the periphery of the wound.
  5. Cover with ________________ if drainage is moderate to heavy.
  6. Secure dressing with _____.
  7. Change dressing according to the frequency noted above or sooner if the dressing is saturated or leaking.
  8. Monitor for signs and symptoms of infection.
  9. Keep pressure off the wound.
  10. Keep wound clean and dry.
  11. Call doctor immediately if wound (s) deteriorates or on a regular basis to report progress.

Doctor's signature and date:


Authored by Dr. Tamara D. Fishman and Dr. Allan D. Freedline. 

Copyright 1995 - 2013