Skin Substitute/CTP Application Procedure Note

Date of Service: [Date]

Start/Stop Time: [Start time – Stop time / Not captured]

Location/Setting: [Clinic / OR / Bedside / Other]

Performing Clinician: [Name, credentials]

Patient Identifiers: [Identifiers per facility policy]

Episode Start Date: [Date of first CTP application in this series]

Application Number: [Application X of Y]

Application Count by Wound: [Per-wound application counts] (Include if multiple wounds treated; otherwise omit.)

Procedure Performed

[Procedure name] — [Anatomic site(s) with laterality] — [Wound identifier(s)] — [Product applied] — [Total treated surface area in cm²] — [Fixation method] — [Secondary dressings]

Indication / Medical Necessity

Ulcer Type and Etiology: [DFU / VLU / Pressure injury / Traumatic / Surgical / Mixed] — [Etiology details]

Chronicity: [First noted/onset date] — [Duration in weeks]

Standard of Care (SOC) Trial:

• SOC Dates: [Start date] to [End date]; Minimum Duration Met: [Yes / No] ([Duration in weeks])
• Baseline at SOC Start: [L × W × D in cm] — [Calculated area in cm²]
• Current Measurements: [L × W × D in cm] — [Calculated area in cm²]
• Percent Area Reduction: [Percent]
• Adherence: [Offloading adherence for DFU / Compression adherence for VLU / N/A] — [Device/modality and adherence details]

Contraindications Assessed and Excluded:

• Active Infection: [Exam findings demonstrating absence: no purulence, no spreading erythema, no warmth, no systemic symptoms] (If infection previously present, document treatment and current controlled status with supporting findings.)
• Ischemia: [No clinical ischemia] — [Perfusion indicators: pulses, capillary refill, skin temperature, prior vascular testing if relevant]
• Necrosis: [No necrosis present] — [Exam findings]

Pre-Procedure

Allergies: [All allergies including product-relevant: bovine/porcine/fish/shellfish, antibiotics, antiseptics, latex]

Consent: [Informed consent obtained today / Prior consent referenced and reaffirmed today] (Procedure, risks, benefits, alternatives discussed; questions answered.)

Time-Out: [Patient identity verified; procedure and site/laterality confirmed; correct product available; expiration date checked]

Anesthesia Plan: [Topical / Local infiltration / Regional block / None] — [Agent, dose, site if applicable]

Wound Assessment (Pre-Application)

(Repeat the following block for each wound treated. If measurements not obtainable, document reason and last measured date. If depth not assessable due to slough/eschar, document and state plan.)

[Wound Identifier]

Location: [Anatomic landmark, laterality, orientation]

Classification: [Wagner grade / University of Texas stage / Pressure injury stage / Other / Not classified]

Measurements: [L × W × D in cm]; [Calculated area in cm²]; [Undermining/tunneling with clock position and depth if present]

Wound Bed: [Tissue type percentages: granulation/slough/eschar]; [Exposed structures if any]; [Exudate amount and character]; [Odor]

Periwound: [Maceration / Erythema / Dermatitis / Callus / Edema / Other findings]

Infection Screening Findings: [Specific exam findings supporting absence or presence of infection]

Perfusion Indicators: [Pulses, capillary refill, skin temperature, prior vascular testing if relevant]

Photo Obtained: [Yes / No]

Wound Bed Preparation

Cleansing/Irrigation: [Solution, technique, volume if relevant]

Debridement: [Method: sharp/curette/mechanical/enzymatic/autolytic] — [Indication] — [Tissue removed] — [Depth: epidermis/dermis/subcutaneous/fascia/muscle/bone] — [Area debrided in cm²] (If no debridement performed, state "No debridement performed today" and the reason.)

Hemostasis: [Method: pressure/topical/electrocautery / Not required]

Post-Preparation Wound Bed Status: [Granulation status, bioburden appearance, readiness for CTP]

Specimens: [Culture/biopsy obtained: site, method, rationale / None]

Product Details

Product Name: [Brand name]

HCPCS Code: [Code and unit definition if known]

Package Size Opened: [Number and size of packages]

Lot/Batch Number: [Number / No lot number per manufacturer labeling]

Expiration Date: [Date]

Storage/Handling: [Confirmed per IFU / Deviations with rationale]

Amount Applied: [cm²]

Amount Discarded: [cm² / 0 discarded]

Reason for Wastage: [Wound size smaller than package / Sterility / Patient safety / Other] (Confirm most appropriate package size selected to minimize wastage.)

Application Technique

[Anesthesia used and patient tolerance]. [Product preparation per IFU: hydration/thawing/rinsing]. [Product trimmed to wound dimensions; fenestrated/meshed if applicable]. [Applied in single layer to wound bed with full contact and no tenting; orientation if applicable]. [Overlap onto intact skin: avoided / used with rationale]. [Surface area applied per wound in cm²]; [Total surface area across all wounds in cm²].

Fixation / Dressings

• Fixation/Anchoring: [Steri-Strips / Sutures / Staples / Adhesive / Bolster / Compression] — [Details]
• Primary Contact Layer: [Non-adherent / Petrolatum gauze / Silicone] — [Details]
• Secondary Dressings: [Absorbent layer / Foam / Gauze / Wrap] — [Details]
• DFU Offloading: [Device type and instructions] (If not used, document contraindication or reason.)
• VLU Compression: [Modality and strength] (If not used, document contraindication or reason.)

Post-Procedure

Patient Tolerance: [Well tolerated / Fair / Poor] — [Pain score if collected]

Hemostasis: [Achieved / Not applicable]

Neurovascular Status: [Intact / Findings] (Include for extremity procedures.)

Complications: [None / Specific complications]

(If procedure aborted: document step at which aborted, reason, and wound protection measures taken.)

Disposition and Plan

• Dressing Care: [Keep intact/dry for X days] — [Who will change and when]
• Activity: [Weight-bearing/offloading instructions; elevation; compression adherence]
• Warning Signs Reviewed: [Infection, increasing pain, bleeding, drainage/odor, fever, worsening erythema]
• Follow-Up: [Timeframe] — [Provider/service]
• Ongoing Plan: [Wound remeasurement before subsequent application; adherence monitoring; systemic optimization: diabetes control, vascular evaluation, nutrition, smoking cessation as applicable]
• Criteria for Next Steps: [Repeat CTP if objective improvement and continued medical necessity] / [Stop or re-evaluate if worsening, no measurable change, or infection/ischemia develops]

Billing Support (Optional)

• Anatomic Site Grouping: [Body areas for coding]
• Wound Surface Areas: [Total cm²]; [Per-wound cm²]
• Units Applied/Discarded/Billed: [Units and basis]
• Applications Beyond Payer Threshold: [Attestation with justification, evidence of progress, expected trajectory, contingency plan] (Include if applicable.)

(If procedure not performed: convert to "Planned But Not Performed" entry documenting reason—infection, ischemia, necrosis, patient intolerance, product unavailable, other. Omit Wound Bed Preparation, Product Details, Application Technique, Fixation/Dressings, and Post-Procedure sections. Include assessment, contraindications, and plan for optimization and rescheduling.)

(Do not infer or backfill chronicity, SOC completion, or measurements. Enter dates and values explicitly; if unknown, state "unknown" and why.)

(Avoid cloned/boilerplate text. Document wound-specific findings and per-wound application counts when multiple wounds are treated.)