Provider Long Term and Post-Acute Care. View Current Issue. Caregiving · All Articles · Clinical · Quality . Sample Wound Care Documentation, Page 1. Wound Assessment Form_1.jpg. Tags: Caregiving, Clinical. Page. Previous; 1; 2; Next . Objectives. • Pressure Ulcer (PU) prevention (6 minutes). • Early Identification (6 minutes). • Management of Wounds (6 minutes). • Introduction to NYGH Documentation process. • Introduction to NYGH Medication Administration Record . 2006/05/24 – Wound assessments, documentation, and treatment plans should only be performed by an RN, MD, PA or ARNP. An MA may assist with wound care, or follow a treatment protocol, if directly supervised by an RN, MD, PA or . 2011/09/06 – Templates, in paper or electronic form, can help ensure complete documentation. If your facility does not . What should providers document and coders look for in order to accurately code for wound care ?Documentation . Documentation Guideline: Wound Assessment & Treatment Flow Sheet. June 2011 Revised July 2014. 1. GENERAL CONSIDERATIONS a. A wound assessment is done as part of the overall client assessment (cardiorespiratory status, . 2012/03/26 – Director of Wound & Continence. Pathway Health Services. March 2012. Wound Care Nurse. Utilized when a wound happens; Typically is responsible for the weekly documentation of a wound; Ensures appropriate treatment . CPD-Final May 2010. Date: May 2010. Page 1 of 9. Clinical Practice Document –. Physiotherapy Role and Scope for Skin and Wound. Management. Site Applicability. Vancouver Coastal Health (VCH) and Providence Health Care (PHC). Mobility status: Good mobility. Bad Mobility. Smoking: Yes. No. If yes, how many/day: Alcohol: units/week. Co-morbidities: Medications: ABPI (if done):. Date: Wound description. Wound type: Duration of wound: Previous treatments: Size: length. Wound Measurement & Documentation Guide. Portions of this material were prepared by Primaris Healthcare Business Solutions. It is provided by Health Quality Innovators. (HQI), the Medicare Quality Improvement Organization for Maryland .