Link Wound to Order Video: Wound Orders Linked To Assessment - YouTube

Each time you assess a wound in your visit note you can have the wound care order automatically show up on the assessment.  The first thing that will need to happen is to have a wound entered in the note and assigned to a number.  Next, you have two different ways you can start a wound order; straight from the Wound Assess screen in the assessment or from the Verbal Order screen.  After you create the wound order and pull up the wound in your assessment, it will show the wound care orders in past tense.   Here are the options below:

Straight from the Wound Assess Screen:

• Start a new wound or pull up an existing wound from Visit / Assessment > Wound Assess screen.
• After assessing and documenting the information for the wound; enter the wound order information in the Comments box at the bottom of the screen.
• Click on the button “Add Wound Order”.  Or, if you are updating the wound order information then the button will say “Update Wound Order”.
• A message will appear stating that a wound order has been created and can be found in the Orders screen > Show Orders – VO Not Needed. If you need to create an order follow the next steps.
• Press the Pause button from the assessment and click on Orders.  Click on the button Show Orders – VO Not Needed. From here you can create a verbal order.
• The next time you assess this wound, the wound orders will show up in the Comments section.  

Create Wound Order from the Order Screen:

• From the assessment create a new wound as needed in the wound assess screen.
• Click on the Pause button from the assessment.
• Click on the Orders button and then enter your Barnestorm password.
• Start to create a verbal order as usual.
• From the Type drop-down list click on Wound.
• From the order builder screen, select the wound you want to assign the orders to.  The wound care orders will not show up on the assessment if you skip this step.
• Click on Create Order.
• This will pull the previous wound documentation.  You can erase all of this data or modify it.
• Enter the wound care orders and then click on Save.
• From here you can turn it into a Verbal Order or No VO Needed – or you can leave it as a pending order until it is complete. 
• Click on Resume from bottom-left to go back to the assessment.
• Select that wound again in the Wound Assess screen.  You’ll notice at the bottom of the page the wound care orders will appear in past tense form.

·         In verbal order screen like this:  CLEANSE WITH SOAP AND WATER. PAT DRY. APPLY DUODERM.

·         Shows up in note as: CLEANSED WITH SOAP AND WATER. PATTED DRY. APPLIED DUODERM.

Example from the Visit / Assessment > Wound Assess screen when entering wound orders for the first time.

Example from the Visit / Assessment > Wound Assess screen when assessing the wound after wound order has already been entered.  Notice it shows up in past tense.