Here is the form..just copied and pasted..easier than trying to fax everywhere, now needs revision re:  ATS, other information needed, but is a good place for anyone who needs it to start.  We send a copy to materials, only way they get a VAC, previously the docs would order "VAC"  and the nurses made up whatever, now with this there are specific instructions to the nurses, discharge planners and the docs on what info is needed.   Thanks for all of the prayers,  Enjoy! Pat McDonald, ARNP, CWOCN


Negative Pressure Wound Therapy (VAC) PRE-PRINTED ORDERS

1. Type of Wound:  Pressure Ulcer,  Neuropathic Ulcer ,  Surgical/Trauma Wound 
(circle most appropriate)          Other____________
2. Wound Location : ________________
3. Wound Dimensions:  Length___________ Width___________ Depth__________
(Please note presence of tunneling or undermining)
4. Type of VAC
Stationary VAC (if expected drainage > 15cc/24 hrs, large or multiple wounds)
   Mini VAC (if expected drainage < 15cc/24 hrs or very small wound)
Deliver VAC to _________________  by __________.
Location date

5. Change dressing; MD or Nursing or CNS (circle who will do the dressing  change)
 In 24 hours then q 48 hrs thereafter
or 
 In 24 hours then q MWF thereafter
Other ______________________
3. Set Suction (circle one)
· at default levels of 125mmHg for stationary VAC or 
· Other    __________________
4. VAC settings:  (circle one)
· Continuous   or   Intermittent 
· Continuous x 24, then Intermittent
5. Wound Consult (call the referral line 4-4810 or pager 4707)
6. Social Service/Case Management Consult (necessary for all VAC dressings for discharge planning). 
7. Dietary Consult for nutrition therapy, if not already done.
8. Measure wound weekly and record length, width, and depth 
9. Type of  Dressing:

Stationary VAC 
Black Small #______ required
Medium #______ required
Large #_______ required
White #_______ required
Mini VAC
Black 1 (one) each  x # dressing changes = total ________
White 1 (one) each x # dressing changes = total _________

10. ADDITIONAL SUPPLIES:
· Cannisters #______ required
· Extension tubing #______ required 
· Extra drape #______ required

11. If being discharged to home with a standard VAC , please order @ discharge:
· A standard suction machine with a back-up battery pack
· Extension tubing.