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Freehand
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Nail Care (NOT BILLED)
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Do not fill out this section if you already did this in Routine Footcare section
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Nails Debrided (Not Billed)
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Which Nails Debrided?
• • •
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Sample of Nail Sent to Path
• • •
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Freehand
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Callus Care (NOT BILLED)
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Do not fill out this section if you already did this in Routine Footcare section
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Calluses Debrided (Not Billed)
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Location of Callus Debridement ("Debridement done to___")
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Additional Callus Info
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Wound Debridement
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Wound Debrided
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1) Which side?
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1a) Debridement Epidermis <20 sqcm
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1b) Debridement of SubQ <20 sqcm
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1c) Debridement Muscle <20 sqcm
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Freehand
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Wart Therapy
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Destruction Procedure Performed
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Cantharone <15 Lesions
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Zuri- Cantharone <15 Lesions
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Cantharone 15 or more Lesions
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HistoFreeze <15 Lesions
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Wart Compound Cream Prescribed
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Freehand
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2 Weeks Post Cantharone Appointment - Plan
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Number of Lesions Debrided (post-catharone)
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Apply Wart Bandaid for next 2 weeks?
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Freehand
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Wound Dressing and Product Applied
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Wound Dressing and Product Applied
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Products Applied
• • •
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Dressing applied
• • •
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Other Applied
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Unna Boot Wrap Applied
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Left Unna Boot Wrap
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Right Unna Boot Wrap
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Other Applied
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Wound Dressing Prescribed
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Wound Dressing Prescribed
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Prisima, Collagen (A6021)
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Number Ordered
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Change Dressing How Often?
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Length of Need
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Number of Wounds
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Alginate (A6196)
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Number Ordered
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Change Dressing How Often?
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Length of Need
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Number of Wounds
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Foam Dressing w Border (A6212)
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Number Ordered
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Change Dressing How Often?
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Length of Need
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Number of Wounds
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Hydrocolloid Dressing w/o Border (A6234)
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Number Ordered
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Change Dressing How Often?
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Length of Need
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Number of Wounds
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Hydrogel Wound Filler (A6248)
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Number Ordered
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Change Dressing How Often?
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Length of Need
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Number of Wounds
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Sample
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Medications Prescribed
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Oral Medication Prescribed
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Topical Medications Prescribed
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Oral Medication Prescribed
• • •
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Other Oral Medication
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Topical Medication Prescribed
• • •
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How often?
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Other Topical Prescribed
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Instructions for Home
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Instructions for Home
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Nursing Instructions
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Home Health Nursing Timing
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Dressing by Home Health
• • •
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Other Wound Care
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Home Care Instructions
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Self Wound Care Timing
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Dressing at Home
• • •
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Other Wound Care
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Soaking Instructions
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Rash Instructions
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Other Instructions Given
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DME and DM Shoes
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DME/Shoegear Recommendations
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Regular Shoe OK
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Recommend Extra Depth Shoes
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Medicare
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Private Insurance
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Sending DM Letter to PCP Today
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Ordering Today
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Diabetic- Shoes Only (Medicare)
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Diabetic- Shoes Only (Private)
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Diabetic- Shoes w 3 Cstm Inserts Today (Medicare)
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Diabetic- Shoes Insurance w 3 Cstm Inserts Today
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Diabetic- Shoes w 3 Pre Fab Inserts Today (Medicare)
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Diabetic- Shoes Insurance w 3 PreFab Inserts Today
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Non Diabetic- Shoes CASH w/ 3 Custom Inserts Today
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Non Diabetic- Shoes CASH w/ 3 Cstm Inserts Today
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Non Diabetic- Shoes CASH w/ 3 Prefab Inserts Today
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Non Diabetic- Shoes CASH w/ 1 Cstm Insert Today
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Non Diabetic- Shoes CASH w/ 3 Prefab Inserts Today
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Ordering Later (Medicare)?
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Ordering Later (Non-Medicare)?
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New DME Prescribed?
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Continue Previous DME
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WBing Status with old DME?
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Previously Dispensed DME*
• • •
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L Foot Prefab DME
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R Foot Prefab DME
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L Surgical Shoe (L3260)
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R Surgical Shoe (L3260)
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L Tall CAM Walker (L4361)
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R Tall CAM Walker (L4361)
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L Short CAM Walker (L4361)
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R Short CAM Walker (L4361)
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L AfterDC Brace (L1902)
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R AfterDC Brace (L1902)
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L Ankle Stirrup (L4350)
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R Ankle Stirrup (L4350)
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L Multiligamentous AFO (L1906)
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R Multiligamentous AFO (L1906)
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L AFO with Ankle Joint (L1971)
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R AFO with Ankle Joint (L1971)
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Other DME Device or WB status
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Weight Bearing Status
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Weight Bearing Status
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Imaging Studies
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Cultures/Advanced Imaging Ordered?
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What was Ordered?
• • •
|
Of What?*
• • •
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Other Imaging
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Activity Level
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Activity Level
• • •
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Excusal Note Provided
|
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If symptoms fail to improve by next visit
• • •
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Other plan not discussed
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New Referral Sent
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New Referral Sent
• • •
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Other doctor not listed
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When to Return?
|
|
|
How many months?
|
2 months
|
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How many weeks?
|
1 month
|
|
How many days?
|
3 weeks
|
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2 weeks
|
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1 week
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PRN
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When Orthotics are Ready
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When Shoes are Ready
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