Additional Documentation Needed - Diagnosis Specific

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Along with referral, please send:

• Progress notes including wound care for past 30+ days with no signs of healing
• HgbA1C (past 6 months)
• Wound infection status 
• Pressure reduction/off loading techniques in use

 Along with referral, please send: 

• Documentation of radiation therapy summary (dates and amount)
• Documentation of symptoms of soft-tissue radionecrosis
• If hemorrhagic cystitis - include copy of cystoscopy

 Along with referral, please send: 

• Documentation in OP note of surgical flap/graft that was created or placed
• Documentation of the compromised or failed flap or graft

 Along with referral, please send: 

• Confirmation of diagnosis via pathology report or diagnostic imaging
• Status of refractory to antibiotics and history of antibiotic treatment

 Along with referral, please send: 

• Documentation of date/type of vascular assessment
• Documentation and date of revascularization procedure, or that patient is not a candidate for revascularization

If your patient has an alternate diagnosis to consider for hyperbaric oxygen therapy, please send referral with most recent progress note and you may contact us to determine what additional documentation may be needed