New Patient Intake Form

Transcription

1 New Patient Intake Form Facility Name: Patient Name: General Patient Information Weight: Height: B/P:! Hospice Past Medical History! DM (Last A1C)! Venous Stasis (Last Venous Doppler)! PAD (Last Arterial Doppler or ABI)! Osteomyelitis! Malnutrition! Gen Weakness Wounds Location Date Acquired Type Stage **Please include additional wounds on a separate sheet. Please fax all new patient information to including: 1. Completed New Patient Intake Form 2. Completed Procedure Consent Form 3. Completed Notice of Privacy Practices 4. Completed Standing Orders Form 5. Patient Face Sheet 6. History & Physical or Hospital Discharge Summary 7. Physician Order for Wound Care Consult Faxes received by 12 noon will be processed by the next business day. Faxes received after 12 noon will be processed within 1-2 business days. Rev Call with any questions.

2 Consent to Wound Care Treatment Patient Name: Date of Birth: Patient hereby voluntarily consents to wound care treatment by United Wound Healing and its respective employees, agents and representatives. Patient understands that this Consent Form will be valid and remain in effect from the date of signature, as long as the Patient receives care, treatment and services by United Wound Healing. Patient has the right to give or refuse consent to any proposed procedure or treatment at any time prior to its performance. 1. General Description of Wound Care Treatment: Patient acknowledges that United Wound Healing and/or its Wound Care Provider has explained that treatment by United Wound Healing may include, but shall not be limited to: debridements, dressing changes, biopsies, physical examinations, diagnostic procedures, laboratory work, x-rays, other imaging studies and administration of medications. Patient acknowledges that United Wound Healing and/or its Wound Care Provider has given Patient the opportunity to ask and have answered all questions regarding the treatments that may be provided by United Wound Healing and its Wound Care Providers. 2. Benefits of Wound Care Treatment: Patient acknowledges that United Wound Healing and/or its Wound Care Provider has explained that the benefits of wound care treatment include: enhanced wound healing and reduced risk of amputation and infection. 3. Risks/Side Effects of Wound Care Treatments: Patient acknowledges that United Wound Healing and/or its Wound Care Provider has explained that wound care treatment may cause side effects and risks including, but not limited to: infection, ongoing pain and inflammation, potential scarring, possible damage to blood vessels, possible damage to surrounding tissues, possible damage to organs, possible damage to nerves, bleeding, allergic reaction to topical and injected local anesthetics or skin prep solutions, removal of healthy tissues and prolonged healing or failure to heal. 4. General Description of Wound Debridements: Patient acknowledges that United Wound Healing and/or its Wound Care Provider has explained that wound debridement means the removal of unhealthy tissue from a wound to promote healing. During the course of treatment by United Wound Healing and/or its Wound Care Provider, multiple wound debridements may be medically necessary and will be performed by an authorized practitioner. 5. Risks/Side Effects of Wound Debridement: Patient acknowledges that United Wound Healing and/or its Wound Care Provider has explained that the risks or complications of wound debridement include, but are not limited to: potential scarring, possible damage to blood vessels or surrounding areas such as organs and nerves, allergic reactions to topical and injected local anesthetics or skin prep solutions, excessive bleeding, removal of healthy tissue, infection, ongoing pain and inflammation, and failure to heal. Patient specifically acknowledges that United Wound Healing and/or its Wound Care Provider has explained that bleeding after debridement may cause rapid deterioration of an already compromised patient and could also result in dissemination of bacterial and bacterial toxins into the bloodstream and thereby cause severe sepsis. Patient also acknowledges that United Wound Healing and/or its Wound Care Provider has explained that debridement will make the wound larger due to the removal of necrotic (dead) tissue from the margin or boarders of the wound.

3 Consent to Wound Care Treatment, page 2 The patient hereby acknowledges that he or she has read and agrees to the contents in sections 1 through 5 of this document. Patient agrees that his or her medical condition has been explained to him or her by United Wound Healing and/or its Wound Care Provider. Patient agrees that the risks, benefits, and alternatives of care provided by United Wound Healing have been discussed with Patient. Patient has read this document or had it read to him/her and understands the contents herein. The Patient has had the opportunity to ask questions and has received answers to all of his or her questions. By signing below, Patient consents to the care, treatment, and services described in this document and orally by United Wound Healing and/or its Wound Care Provider. Signature of Patient: Date: Time: Facility: Signature of Parent/Conservator/Guardian: Name of Parent/Conservator/Guardian: Date: Time: If signed by other than patient, indicate relationship: The undersigned Wound Care Provider has explained to the Patient (or his or her legal representative), in layman s terms, the nature of the treatment, reasonable alternatives, benefits, risks, side effects, likelihood of achieving patient s goals, complications and consequences which are/or may be associated with the treatment procedure(s). Signature of Wound Care Provider: Date: Time: Please fax completed form to: Rev

4 Patient HIPAA Rights, Notice of Privacy Practices, and Consent Form HIPAA: Patient Rights This document is designed to give you information about how United Wound Healing may use your information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Patient Rights under HIPAA Patients are entitled to more information about and more control over their own health information. The patient rights are: 1. The Right to Receive a Notice of Privacy Practices 2. The Right to Access Protected Health Information 3. The Right to Amend Protected Health Information 4. The Right to an Accounting of Disclosures of Protected Health Information 5. The Right to Request a Specified Method of Communication 6. The Right to Request Restrictions on Use and Disclosure of Health Information 1. The Right to Receive a Notice of Privacy Practices - HIPAA requires United Wound Healing to provide each patient, at or prior to the first provision of care, a Notice of Privacy Practices. Any person who asks for a copy of United Wound Healing s Notice of Privacy Practices will be provided a copy. 2. The Right to Access Protected Health Information under HIPAA - Every patient has a right to examine and, if he or she wishes, to receive a copy of all the health information United Wound Healing has for him or her. This right extends to both medical and billing records. If a patient would like a copy of his or her Protected Health Information, United Wound Healing may charge a reasonable, cost-based fee for providing this. If the health record is maintained in electronic format by United Wound Healing, then United Wound Healing is required to provide an electronic copy to the patient and to whomever the patient identifies. In some cases, access to Protected Health Information may be legitimately denied. 3. The Right to Amend Protected Health Information - Once a patient accesses his or her health information, he or she may correct information that is incorrect or missing. Oral requests for changes can only be accepted to correct typos, change demographic information, update insurance information, and correct billing or processing errors. All other requests for changes must be submitted in writing sent to our office at th Ave. NE, Ste. 101, Puyallup, WA If you have questions regarding requests for changes, you may contact us at The Right to an Accounting of Disclosures - A disclosure is a release of information outside of United Wound Healing. Sometimes United Wound Healing discloses health information for reasons other than treatment, payment, or health care operations, under circumstances where the patient is not required to sign an authorization for the disclosure. Examples of this are public health activities (reporting immunizations, birth and death certificates, cancer/tumor registries, pregnancy terminations), reports 1

5 about victims of abuse, neglect, or domestic violence, information used for organ or tissue donation and transplantation, disclosures about decedents to coroners, medical examiners, or funeral directors, and other disclosures required by law. If a patient wants an accounting of disclosures, he or she must submit a written request. 5. The Right to Request a Specified Method of Communication - At times, patients may ask that United Wound Healing communicate with them in special ways. These requests may involve a single service area or multiple service areas. Examples of Requests That Involve a Single Service Area: Please don t leave appointment reminders on my answering machine. When you call me please only use this number. Examples of Requests that Involve Multiple Areas: Please have the billing department send my bill to my mother s house. Please don t leave test results on my answering machine or voice mail. We can only accept requests that impact a single service area. If a patient makes a request that involves multiple areas, it is up to him or her to coordinate this with each area directly. A patient may request a specified method of communication either orally or in writing. 6. The Right to Request Restrictions on Use and Disclosure of Health Information - Patients have the right to request restrictions on: A. The use and disclosure of Protected Health Information for treatment, payment, and health care operations B. Disclosure of Protected Health Information to family members, friends, and others involved in their care If a patient would like to request a restriction of use and disclosure of Protected Health Information for treatment, payment, and/or health care operations, this request must be made in writing. Please send requests to United Wound Healing Office of Information Privacy and Security. If a patient requests that United Wound Healing not share his or her Protected Health Information with family, friends, or others involved in his or her care, he or she may do this orally. We will do our best to accommodate all reasonable requests, and will document the request and the decision to share or not share in the patient s chart. A patient can terminate these restrictions orally (if so, document in chart) or in writing. United Wound Healing may also terminate restrictions that the company has agreed to by notifying the patient in writing. Rev

6 The patient understands that: 1. Protected health information may be disclosed or used for treatment, payment, or health care operations. 2. United Wound Healing has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. 3. United Wound Healing reserves the right to change the Notice of Privacy Practices. 4. The patient has the right to restrict the uses of his or her information, but United Wound Healing does not have to agree to the restrictions. 5. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. 6. United Wound Healing may condition receipt of treatment upon the execution of this Consent. 7. The patient acknowledges that he/she has received a copy of this form. Please sign for receipt of this form. Patient Name: Signature of Patient: Date: Signature of Parent/Conservator/Guardian: Date: If signed by other than patient, indicate relationship: Rev

7 Standing Orders for Wound Care Patients Seen by United Wound Healing Patient Name: Facility Name: Date: 1. Lidocaine 4% gel ointment, apply a thin layer of lidocaine 4% topically to each wound and cover with a clear tegaderm dressing minutes prior to each surgical wound debridement PRN. 2. Silver Nitrate to be applied to wounds status post-surgical wound debridement PRN. Primary Care Physician Signature Rev Please fax completed form to