Get the free WOUND CARE REFERRAL FORM - onsite4seniors

REVISED FORM JUNE 2014 Date: ON SITE FOR SENIORS, INC. WOUND CARE REFERRAL FORM PO Box 238 Hayden, ID 83835 Tel. 2086643301 Fax 8776532694 Lynda Arnold, ARP, CWC Patients Name: DOB: Family/Contact

How to fill out wound care referral form

How to Fill Out a Wound Care Referral Form:

1. Obtain the form: Contact the healthcare provider or facility that requires the referral form and request a copy. They may provide it in person, through email, or on their website.
2. Gather necessary information: Before starting to fill out the form, collect all relevant information that may be required. This may include the patient's name, contact information, medical history, insurance details, referring physician's information, and details about the wound or injury being treated.
3. Complete patient details: Begin by entering the patient's full name, date of birth, address, phone number, and any other required personal information. Double-check for accuracy to ensure proper communication.
4. Specify the referring physician: Provide the name, contact details, and any additional information of the referring physician or healthcare provider who is recommending the wound care treatment. This information helps in maintaining proper coordination and communication between healthcare professionals.
5. Record medical history: List any relevant medical conditions, allergies, ongoing medications, and previous surgeries or procedures that may impact the wound care treatment. Include the dates and details for proper assessment and appropriate wound care management.
6. Describe the wound or injury: Provide a comprehensive description of the wound or injury being referred for specialized care. Include details like location, size, depth, possible causes, and any additional relevant information that can assist the wound care specialist in understanding the condition.
7. Include supporting documents: If available, attach any relevant supporting documents such as medical reports, imaging results, lab tests, or previous wound care records. These documents can provide valuable insights and aid in the assessment and treatment planning.
8. Review and sign: Carefully review all the entered information for accuracy and completeness. Ensure that all sections of the form are duly filled out. Lastly, sign and date the referral form, indicating your consent and agreement to proceed with the referral.

Who Needs a Wound Care Referral Form:

1. Patients with complex wounds: Individuals who have wounds that require specialized care and treatment, such as chronic wounds, surgical wounds, diabetic ulcers, pressure ulcers, burns, or non-healing wounds, may require a wound care referral form.
2. Primary care physicians: Physicians who assess patients with significant wounds and determine the need for advanced wound care may initiate a wound care referral. They refer patients to wound care specialists or wound care centers for specialized treatment procedures.
3. Specialized healthcare providers: Other healthcare professionals, such as surgeons, podiatrists, dermatologists, or nurses who encounter complex wounds, may also need to complete and submit a wound care referral form when transferring the patient to a wound care specialist.

Remember, the specific requirements for a wound care referral form may vary between healthcare providers, facilities, and regions. It is essential to carefully follow the instructions provided by the referring entity to ensure a seamless referral process and proper continuity of care.

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What is wound care referral form?

The wound care referral form is a document that healthcare providers use to refer a patient to a wound care specialist for specialized treatment.

Who is required to file wound care referral form?

Healthcare providers such as doctors, nurses, or other medical professionals are required to file the wound care referral form on behalf of their patients.

How to fill out wound care referral form?

To fill out the wound care referral form, healthcare providers must provide patient information, details about the wound, medical history, and reason for the referral.

What is the purpose of wound care referral form?

The purpose of the wound care referral form is to ensure that patients receive appropriate and timely treatment for their wounds from specialized wound care providers.

What information must be reported on wound care referral form?

Information such as patient demographics, wound location and size, medical history, current treatment plan, and reason for the referral must be reported on the wound care referral form.