Wound Care Medical Necessity Assessment Form

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    1. Location
      • Descriibe wound location
    2. Size: Length, Width, Depth(cm)
      • [length], [width], [depth]
    3. Drainage:
      • Mild - 1
      • Moderate - 2
      • Heavy - 3
    4. Thickness:
      • Partial - 1
      • Full - 2
    5. Color
      • Clear - 1
      • Serosanuineous - 2
      • Bloody - 3
      • Yellow - 4
      • Brown - 5
      • Other: - Describe
    6. Odor
      • No - 1
      • Yes - 2
    7. Tunneling/Undermining
      • No - 1
      • Yes - 2
    8. Primary Bandage Size
      • [4in x 4in] - 1
      • [7in x 7in] - 2
    9. Secondary Bandage Size
      • 16in2-48in2
      • 48in2+
    1 Location2 Size3 Drainage4 Thickness5 Color6 Odor7 Tunneling8 Primary Bandage Size9 Secondary Bandage Size10 Dressing Changes per day 
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