Home Health Wound Care Referral/Orders

Order date: [Order date]

Patient name: [Full name]

DOB: [DOB]

Address: [Street, City, State, ZIP]

Phone: [Patient phone]

Ordering clinician: [Name, credentials]

Clinician phone/fax: [Phone] / [Fax]

Preferred contact method: [Phone / Secure message / Fax]

Receiving home health agency: [Agency name if known]

Referral Summary

• Primary reason for referral: [Wound care orders for specified wounds as listed in Wound Index]
• Clinical objectives: [Promote granulation / Prevent infection / Control bioburden / Manage exudate / Maintain perfusion / Protect periwound / Reduce edema / Pain control]
• Start of care requested within: [24-48 hours / 72 hours / 1 week]
• Pertinent comorbidities affecting wound healing: [Diabetes / PAD / Venous disease / Neuropathy / CHF with edema / CKD / Immunosuppression / Malnutrition risk / Anticoagulation / Other] (Include only those applicable.)
• Relevant allergies/sensitivities: [Adhesive / Iodine / Silver / Latex / Topical antibiotics / None known / Unknown—HHA to assess]

Medicare Coverage Support

(Include when Medicare or similar payer requirements apply; omit if not applicable.)

• Homebound status: [Functional limitations making leaving home a considerable and taxing effort / HHA to assess]
• Skilled need: [Skilled nursing required for complex wound assessment, dressing regimen, infection monitoring, patient/caregiver teaching]
• Face-to-face encounter: [Date]; [Clinician type: MD / DO / NP / PA]; encounter related to home health need confirmed

Wound Index

(List all active wounds. Assign stable identifiers that persist across the episode. Add or remove rows as needed.)

Wound #	Anatomic Location (with laterality)	Etiology/Type	Onset/Chronicity	Current Status
Wound #1	[Location with laterality]	[Pressure injury / DFU / VLU / Arterial ulcer / Surgical / Traumatic / Skin tear / Other]	[Onset date or duration]	[Improving / Stable / Worsening / Unknown]

Wound Detail

(Repeat this section for each wound. If details unavailable, document "Unknown—HHA to assess" or "Not measured—HHA to measure at SOC" rather than leaving blank.)

Wound #[X] Detail

• Measurements: [Length × Width × Depth in cm]; [Undermining/tunneling with clock-face locations and depth] or [Not measured—HHA to measure at SOC]
• Drainage: [None / Scant / Light / Moderate / Heavy]; [Serous / Serosanguinous / Sanguineous / Purulent]; odor after cleansing: [None / Mild / Strong]
• Wound bed: [Granulation / Slough / Eschar / Epithelialization / Mixed]
• Periwound: [Intact / Maceration / Rolled edges / Erythema / Edema / Callus / Dermatitis]
• Pain: Baseline [0-10]; Procedural [0-10]
• Infection status: [No signs / Suspected / Confirmed / Unknown]; local signs if present: [Increasing pain / Erythema >2 cm / Warmth / Edema / Purulence / Malodor]
• Vascular context: (For leg/foot wounds) [ABI/toe pressures if known]; PAD: [Yes / No / Unknown]; revascularization history: [Details / None]
• Prior treatments and response: [Previous dressings/products and observed effectiveness]
• Contraindications/precautions: [Fragile skin / Bleeding risk / Adhesive allergy / Suspected ischemia / None identified]

Skilled Nursing Orders

• Scheduled visits: [Number] visits per week × [Number] weeks for wound assessment, dressing changes, infection monitoring, and caregiver teaching.
• PRN visits: Up to [Number] additional visits per week for: [Dressing saturation within 24 hours / Increased drainage or odor / New or worsening periwound erythema / Uncontrolled pain / Suspected infection]. Notify ordering clinician same day when PRN criteria met.

Additional disciplines: (Include only if ordered.)

• PT: [Frequency × duration] for [Gait/balance training / Offloading device training / Fall risk mitigation]
• OT: [Frequency × duration] for [ADL adaptations / Device use / Caregiver training]
• MSW: [Frequency × duration] for [Resource coordination / Psychosocial support]
• Home Health Aide: [Frequency × duration] for personal care only (not skilled wound tasks)

Wound Treatment Orders

(Repeat for each wound using the same wound identifier.)

Wound #[X] Treatment Orders

Cleansing: [Normal saline / Wound cleanser] with [Gentle irrigation / Cleanse] each dressing change. Protect periwound with [Barrier film / Zinc oxide / Moisture barrier] as indicated.

Dressing Protocol:

• Primary/contact layer: [Product class] for [Exudate management / Autolysis / Antimicrobial coverage]. Packing if tunneling/undermining: [Pack loosely to specified depth using product, leaving tail visible; do not overpack].
• Secondary dressing: [Absorbency level]; [Product type]; secure with [Soft cloth tape / Wrap / Tubular net].
• Change frequency: [Every 24-48h / Every 48-72h / Specific days] performed by [RN / Trained caregiver]. Early change if strike-through, saturation, dislodgement, or soiling.

Topicals: (If ordered.) [Medication name/concentration]; apply to [Wound bed / Periwound] [Frequency]. Stop if rash, irritation, or hypersensitivity, or after [Duration] unless renewed.

NPWT: (If ordered.) [Device type]; [Pressure setting in mmHg, continuous/intermittent]; interface [Foam / Gauze]; change every [48-72 hours or per manufacturer]. Hold for active bleeding, seal loss >2 hours, severe pain, or suspected infection spread.

Offloading Orders

(Include for DFU or pressure injuries; omit if not applicable.)

• Device: [Non-removable knee-high device / Removable walker boot / Surgical shoe with offloading insert / Felted foam / Heel protector / Specialty cushion]
• Adherence: For removable devices, wear during all weight-bearing; remove only for hygiene and dressing changes.
• Weight-bearing status: [WBAT / Partial WB with device / Heel WB only / Non-weight-bearing]
• Repositioning: (For pressure injuries.) Turn/reposition at least every 2 hours in bed; heels offloaded at all times; limit sitting to [Duration] with pressure-redistributing surface.
• PT involvement: [Yes / No]; focus on [Gait training / Device use / Balance]

Compression Orders

(Include for VLU or edema-related wounds; omit if not applicable.)

• Vascular safety prerequisite: [ABI/toe pressure values if known]. If unknown or PAD suspected, obtain vascular assessment prior to moderate/high compression. Interim management: leg elevation, light tubular compression only.
• Compression type: [Multilayer wrap / Short-stretch wrap / Stockings class/pressure / Intermittent pneumatic compression]; target [mmHg range]; wear schedule [Daytime / All day except hygiene]; change frequency [Every 48-72h / Weekly / Per exudate level].
• Skin checks: Inspect toes and periwound at each visit for ischemia, pressure injury, and drainage.
• Hold/stop parameters: New ischemic pain, pallor/coolness, cyanosis, numbness, rapidly worsening edema, or new compression-related wounds—hold compression and notify clinician same day.

Debridement Authorization

(Include only if debridement authorized.)

• Authorized: [Yes / No]
• Permitted methods: [Autolytic / Enzymatic / Mechanical / Conservative sharp] by [RN per agency policy / WOC nurse / NP/PA/MD]. Debride devitalized tissue only; stop for bleeding, uncontrolled pain, or suspected ischemia.
• Contraindications: Stable dry heel eschar without infection (monitor only), critical limb ischemia, uncontrolled bleeding risk.

Monitoring Cadence

• Measurements: At SOC, weekly thereafter, and with notable change; document L×W×D and undermining/tunneling with clock-face orientation.
• Photography: (If used.) Consent: [Obtained / Declined]; cadence: SOC and weekly; store per agency compliant workflow.

Escalation Parameters

(Report wound identifier, measurements, vitals, infection signs, and pain level with all escalations.)

• Emergent (ED/911): Uncontrolled bleeding, rapidly progressive necrosis with systemic signs, suspected sepsis, acute limb threat (sudden severe pain, cold/pale limb, loss of sensation or motor function).
• Urgent same-day notification: New purulent drainage or malodor, new/worsening cellulitis, rapidly increasing drainage, exposed tendon/bone, deterioration despite adherence, compression intolerance or ischemic symptoms.
• Routine (48-72 hours): No improvement by checkpoint, supply issues, caregiver unable to perform interim changes.

Primary contact: [Ordering clinician name] at [Phone/secure message]. After-hours: [On-call contact instructions].

Supplies and Caregiver Role

• Supplies by wound: [Cleanser, primary dressing, packing material, secondary dressing, securement, barrier, topicals, compression/offloading components as applicable]
• Caregiver availability for interim changes: [Yes / No / Unknown]
• RN teaching expectation: Provide education and document return demonstration by visit #[Number].

Follow-Up

• Clinic follow-up: [Date or timeframe]
• Triggers for earlier evaluation: [Lack of improvement by specified week / Increased pain or drainage / Suspected infection / Device intolerance]
• Product substitutions: [Require new orders / Allow substitutions within class for availability—notify clinician of changes]

Signature

Ordering clinician signature: [E-signature acceptable]

Date/Time: [Date and time signed]

If verbal order: Documenting clinician: [Name]; received: [Date/Time]; countersignature required within [Timeframe] per policy.