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Be sure to document the following:
TYPE OF WOUND: Pressure, Traumatic/ Burn, Venous, Vascular (Arterial)
LOCATION OF WOUND
SIZE OF WOUND including length, width and depth
DRAINAGE type and amount
WHAT YOU DID TO THE WOUND including cleansing, debriding, dressing
In NURSING ORDERS note the above but also make a suggestion for wound care dressing(s) and frequency. Be sure to note the NURSING AGENCY
If the NURSING ORDER is a NEW REFERRAL, complete a FACE-TO-FACE (in EPIC Letters) for all medicare patients