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Importance of Proper Wound and Skin Care
Documentation is the pathway to appropriate treatment decisions, evaluating the progress of skin and wound healing, protection against litigation, and supporting payment decisions. Therefore, standardizing documentation throughout your organization is paramount for promoting quality care within a seamless system.
Unique Documentation System
WCS is the first to create a comprehensive documentation system and reference materials for skin and wound care. Used in tandem, these forms provide for the most state-of-the-art, comprehensive Documentation System available. Certain forms are printed on colored paper stock for ease of identification. The color-code pages prompts the caregiver to use these forms systematically.
Types of Forms
The following documentation forms are available with corresponding policies and procedures:
Staff Competency Validation Tools
· Competency Validation: Wound Assessment for the Licensed Clinician
· Competency Validation: Wound Measurement and Documentation for the Licensed Clinician
· Competency Validation: Dressing Change for the Licensed Clinician
· Competency Validation: Ostomy Assessment*
· Competency Validation: Changing an Ostomy Pouch
· Competency Validation: Urinary Incontinence Assessment for the Licensed Clinician
· Competency Validation: Photography Documentation and Importing Photographs
· Care Planning Development: Pressure Ulcer
· Competency Validation: TriAssess Software, Premier Version /
Administrator/Program Director**
· Competency Validation: TriAssess Software, Premier Version / Billing/Coding Specialist**
· Competency Validation: TriAssess Software, Premier Version / Clinician**
· Competency Validation: TriAssess Software, Premier Version / Office Administrator**
· Competency Validation: TriAssess Software, Premier Version / Physician**
· Performance Appraisal: Wound Care Clinician
Assessments: Patient
· Admission Assessment (Original Form Color: White)
· Skin Assessment Tool (Original Form Color: Orange)
· Nutritional Screening Form (Original Form Color: Ivory)
· Contracture Assessment Tool (Original Form Color: Blue)
· Lower Leg Assessment Tool & Monitor (Original Form Color: Lavender)
· Foot Assessment Tool & Monitor (Original Form Color: Canary)
· Pain Assessment Tool & Monitor (Original Form Color: Yellow)
· Wound/Skin Assessment Tool (Original Form Color: Pink)
· Ostomy Assessment Tool* (Original Form Color: Buff)
· Photographic Evaluation Tool (Original Form Color: White)
· Tracking Form: Wound/Skin Care (Original Form Color: White)
· Urinary Incontinence Assessment Tool
· Quality of Life Patient Survey
Audit, Evaluation and Training
· Patient Information Sheet**
· Patient History Form**
· Care Planning Audit: Wound and Skin
· Medical Necessity Review Checklist
· Audit Tool: Wound/Skin Care
· Education and Compliance Audit
· Nutrition Assessment Audit
· Pain Assessment Audit
· Positioning and Support Surfaces Assessment Audit
· Pressure Ulcer Assessment Audit
· Medical Necessity Review Checklist
· Team Meetings and Recommendations Tool
· Staff Satisfaction Survey: Wound Care
* Available soon.
**Available only with TriAssess Software, Premier Version, Library of Standards.
Ease of Use
Each of the forms has a policy and procedure to aid the practitioner in the documentation of the patient's wound(s). These documents are available free of charge to users of the documentation system. The algorithm below provides the beginning step-by-step approach to understanding how the Documentation System works.
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Order Documentation Forms
For assistance Contact WCS.
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