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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.

     Order Documentation Forms

     For assistance Contact WCS.

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