1. Prescriber Aware of Consult?
Yes or No
2. Was consent obtained from the Client/SDM using the script?
Yes or No
It is recommended that the script (attached here
) is used to ensure providers obtains consent. The script is required to ensure privacy when verbally administering consent. The consent does not need to be in writing, but it must be clearly explained so that the resident/client or Substitute Decision Maker fully understands what they are consenting to.
This script has been emailed to service provider and is also available here
3. SDM notified of consult?
Yes or No or N/A
4. Reason for Referral - Select all that apply
- Wound failure to heal - no wound improvement with current treatment being used for 4 weeks
- Wound increasing in size - measurement indicates increase in width, length, or depth
- New to wound care - require assistance
- Challenging wound
- Negative Pressure Wound Therapy (NPWT)
4. Type of Wound - Please select the type of wound, single choice
- Deep Tissue Injury: Persistent non-blanchable deep red, maroon, or purple discoloration
- Stage 2: Partial-thickness skin loss with exposed dermis including intact blister
- Stage 3: Full-thickness skin loss
- Stage 4: Full-thickness skin and tissue loss
- Unstageable: Obscured full-thickness skin and tissue loss
- Venous Leg Ulcer
- Arterial Ulcer
- Mixed Disease (Arterial and Venous)
- Diabetic Ulcer
- Skin Tears
- Surgical Wound
5. Service Provider Key (Required to answer)
Please contact Health Association Nova Scotia to receive your Service Provider key
Once the referral form is completed using unique ID number that has been provided by the wound consultants, the form will be securely submitted via a link, encrypted in transit.
- The consultant will review the referral and contact the service provider by phone to discuss.
- The consultant will may offer a virtual or in house visit to the person with the wound
- Upon completion of the visit the consultant will close the referral process and send a summary of suggestions to the service provider via MoveIt (secure file transfer tool). The suggestions will be sent to the service provider in a timely manner, to support accuracy of information.
Consent for the collection (and use and disclosure) of information will be expressly obtained in two ways.
First, service providers administer their facility’s consent form on admission, which obtains consent from the resident/client (or their SDM as per PHIA s.21 through s.23) to the provision of care from the service provider, and for the collection, use and disclosure of personal health information in the course of providing that care.
Secondly, the service provider will obtain verbal consent from the resident/client or their SDM, as applicable, for referral to the Wound Management Program, and for their de-identified information to be reported by HANS to DHW for the purposes of program evaluation and monitoring. This consent will be conducted using a script and consent will be noted by the service provider in the resident/client file (in compliance with PHIA s.16).
No personal health information will be shared with DHW for this purpose. Any PHI collected will be de-identified and shared with DHW for the purposes of evaluation and monitoring the Wound Management Program.