Negative Pressure Wound Therapy
Order Instructions

Complete the Patient Information sheet.

Complete Wound Assessment Sheet for each wound requiring NPWT.

Obtain signed Physician’s Order.

Fax documents to (757) 640-0136.

Upon receiving the order and completed paperwork, Tycon Medical will contact you and arrange a
delivery time.
Tycon NPWT Contact:
Emily Barberi
ebarberi@tyconmedical.com
757-995-1711 (direct dial)
Quick Order Form for NPWT
FAX to Tycon Medical
From:
(The contact person for this order)
Fax: 757-640-0136
Phone: 757-640-1709
800-411-1739
Your Title:
Facility Name:
Phone:
Fax:
A. Patient’s name and delivery information.
Patient’s Name:
Patient’s Address:
City:
State:
Zip:
Phone:
Alternate Family Contact:
Phone:
Delivery address (if different than above):
City:
State:
Zip:
Phone:
Requested Delivery Date:
AM or PM Delivery:
The NPWT will be used in what type of Facility:  Private Residence Nursing Facility
 LTAC  Rehab  Assist. Living  Group Home  Custodial Care  Other
Name of Facility:
B. Patient’s Insurance Information.
Patient’s DOB:
Primary Insurance:
 Medicare
 Private Insurance
Private Insurance Address:
Policy #:
Group Name:
Secondary Insurance:  Medicare
 Private Insurance
Private Insurance Address:
Policy #
Group Name:
C. Physician’s Information
Physicians Name:
Street Address:
City:
SS#:
HIC#:
Private Insurance Name:
Group #:
HIC#:
Private Insurance Name:
Group #:
NPI:
State:
D. Home Health Information.
Name of Organization that will be following patient in the home:
Address:
City:
Organization Phone:
Fax:
Contact Name:
Contact Phone:
Phone:
Fax
Zip:
State:
Zip:
Wound Assessment
Patient Name (print): ______________________________________ SS#: ________________________
Location: ________________________ Wound age: _________________________
1. PATIENT’S WOUND HISTORY
1. Was NPWT initiated in an inpatient facility? If YES, please complete the following if NO, skip to #2: Yes  No
a) Facility: __________________________________________________________
b) Date NPWT was initiated: ____________________
2. Where are the patient records of history, previous treatment, current treatment and wound measurements located?
Location: ___________________________________________________________
3. Is the patient’s nutritional status compromised? Yes  No
 Protein Supplements  Enteral/NG Feeding  TPN  Vitamin Therapy  Special Diet
4. Which therapies have been previously utilized to maintain a moist wound environment?
 Saline/Gauze  Hydrogel  Alginate  Hydrocolloid  Absorptive  Other: ______________
5. Is necrotic tissue with eschar present in the wound?
 Yes  No
a) Was debridement of the eschar attempted?
 Yes  No
6. Is necrotic tissue without eschar present in the wound?  Yes  No
a) Was debridement of the eschar (slough) attempted, or considered and ruled out?  Yes  No
7. a) Is untreated osteomyelitis present within the vicinity of the wound?
 Yes  No
b) Is cancer present in the wound?
 Yes  No
c) Is there a fistula to an organ or body cavity within the vicinity of the wound?
 Yes  No
2. WOUND TYPE – Complete only the section for the wound being treated.
PRESSURE ULCER:  Stage III  Stage IV
1. Is the patient being turned/positioned
2. Has a group 2 or 3 surface been used for ulcer located on the posterior trunk or pelvis?
3. Are moisture and/or incontinence being managed?
DIABETIC
AND/OR NEUROPATHIC ULCER:

1. Is foot pressure being reduced?
2. Patient on a comprehensive diabetic management program?
VENOUS
STASIS ULCER:

1. Are compression bandages and/or garments being consistently applied?
2. Is elevation/ambulation being encouraged?
CHRONIC
ULCER OF MIXED ETIOLOGY INCLUDING ARTERIAL INSUFFICIENCY:

1. Is pressure over the wound being relieved?
2. Is moisture/incontinence being controlled?
 TRAUMATIC/SURGICALLY CREATED
 Traumatic (i.e. pre-operative flap or graft  Surgically created (i.e. dehisced)
1. Is there documentation of the medical necessity for accelerated formation of granulation tissue
which is not achievable with other topical wound treatments?
2. Is the wound a direct result of an accident?
Date of accident: ___________________
If you answered “No” on any of the above, please explain:

No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
3. WOUND MEASUREMENTS
a) Current (within last 7 days):
b) 1 or more months ago (if available)
Date: ______/______/_______
Date: _____/_____/_____
L: _____cm W: _____cm D: _____cm
L: _____cm W: _____cm D: _____cm
Sinus/Tunnel #1: _____cm @ ______ o’clock
Sinus/Tunnel #1: _____cm @ ______ o’clock
Sinus/Tunnel #2: _____cm @ ______ o’clock
Sinus/Tunnel #2: _____cm @ ______ o’clock
Undermining: _____cm @ ___ to _____o’clock
Undermining: _____cm @ ___ to _____o’clock
Exudate: ___ none ___ min ___ mod ___ heavy
Exudate: ___ none ___ min ___ mod ___ heavy
_________ cc’s per day (if known)
_________cc’s per day (if known)
c) If wound length, width or depth information (i.e. a flap or graft or stasis ulcer without significant depth) is non-applicable,
please explain: ____________________________________________________________________________________
d)  Check this box if you would like to select the wound dressing kit for the patient. (see page 6)
 Check this box if you would like Tycon Medical, Inc to select the appropriate wound dressing kit.
Clinician’s Signature:
Clinician’s Name:
_______________________________________
_______________________________________
Date: _________________
Physician’s Order
Order Date:________________
Patient Name: _____________________________ DOB: ____________
Address: ___________________________________________________
Phone: _______________________ Date: ________________________
Rx:
Negative Pressure Wound Therapy
Prescribed Pressure Setting: ___________________
Mode: Continuous / Intermittent
(Recommended mode is continuous)
I prescribe NPWT therapy and up to 15 therapy dressings per wound and up to 10 therapy
canisters per month for ______ months, starting therapy on ____/____/____ for the
following diagnosis (ICD-10 or narrative):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Goal for completion of therapy:  Complete epithelialization  Graft  Free Flap
 Promote granulation formation  Flap
 Other: _______________________________
Signature of Physician: ______________________________
Physician Name:
Physician Phone #:
______________________________
______________________________
NPI#: ___________________________
Please fax to 757-640-0136
Date: _______________