When to use this checklist

This discharge planner wound referral checklist is for hospital case managers, social workers and discharge planners arranging wound follow-up for a patient who is going home, to a skilled nursing facility, to assisted living or to rehabilitation.

Gateway arranges that follow-up with partner clinicians across Greater St. Louis and the Metro East and coordinates the records, orders, supplies and communication around each visit. The treating clinician makes the clinical decisions. Start the referral as soon as it is clear the patient will leave with a wound that needs follow-up. A referral that begins on the morning of discharge leaves little room to confirm anything.

Before you call

Have these ready:

  • Your organization, unit and direct line, and who covers when you are off
  • The patient’s destination by city or ZIP, and the care setting
  • The anticipated discharge date, and how firm it is
  • The wound type and location in general terms, and any devices such as negative pressure therapy, drains or compression
  • The payer, and the plan’s case manager if one is assigned
  • The receiving contact: the facility’s admissions nurse, or the family member who will be at home
  • Clinicians already involved, including primary care, surgery, vascular, podiatry and any home health agency selected
  • Whether the patient or representative has agreed to the referral and expects a call

Call 314-325-0126, or use the referral request to ask for a callback. The web form takes contact details only. Keep patient names, diagnoses, photographs and records out of it.

Records to send

Referral documents can be faxed to 314-786-7966. Ask us if your team needs a different secure method. The treating practice will usually want:

  1. Face sheet with demographics and insurance
  2. Discharge summary, or the most recent progress notes if the summary is not finished
  3. Current wound orders: dressing, frequency and who performs the change
  4. The most recent wound assessment with measurements and the date taken
  5. Medication list and allergies
  6. Relevant results, such as cultures, vascular studies and imaging, with a note of anything still pending
  7. Operative notes for surgical wounds, grafts or flaps, including the surgeon’s restrictions
  8. Home health and equipment orders already placed

Send what you have instead of holding the packet until it is complete, and note what is still to come. Our guide to the discharge to home wound handoff covers the clinical content in more depth.

Confirm before the patient leaves

Settle four points before the discharge instructions are printed:

  • Acceptance and availability. Gateway confirms whether a visit can be arranged for that address and care setting. Do not write the follow-up into the instructions until it is confirmed.
  • Orders for the gap. Whoever changes the dressings between discharge and the first visit needs active wound orders from the discharging team.
  • The next contact on each side. One name and number at the hospital, one at Gateway and one at the receiving end.
  • Other follow-up. Appointments with the surgeon or specialists still stand. A wound visit does not replace them.

Supplies, equipment and transportation

Check each one:

  • Dressing supplies to cover the first days, according to your hospital’s practice
  • For negative pressure therapy, the device, the supplier and who will change it. See wound VAC follow-up at home.
  • Support surfaces, offloading devices or other equipment the plan depends on
  • Who will follow up on pending cultures, imaging or other ordered services
  • Access at the home: stairs, entry codes and who answers the door
  • Transportation to any outpatient appointments

For visits we arrange, Gateway helps with wound supplies and equipment coordination. Coverage of any item depends on the patient’s plan and the supplier.

What the patient and family should hear

Before discharge, tell the patient and family:

  • Gateway Wound Care will call to arrange the visit and can be reached at 314-325-0126
  • The clinician who visits is from a partner practice and will make the treatment decisions
  • Whom to call about the wound before that first visit takes place
  • That Gateway is not an emergency service, and to call 911 for an emergency

The hospital discharge family checklist is written for caregivers and can go home in the discharge folder.

After discharge

Tell us if the discharge date or destination changes, or if the patient is readmitted. Our pages for hospitals and discharge planners and wound follow-up after hospital discharge explain how we work with hospital teams.

Common questions

Can I refer a patient before the discharge date is set?

Yes. Give us the expected window and the likely destination, then update us as the plan firms up. Early notice leaves time to review records and to confirm whether visits can be arranged for that address. Gateway does not promise visit timing, so ask early.

What changes if the patient is going to a skilled nursing facility instead of home?

The facility’s nurses and attending physician direct daily care, so a visit from a partner clinician needs the facility’s agreement and typically an order. Give us the facility’s name and admissions contact. We confirm with the building whether visits can be arranged there. Send the wound orders and records to the facility as you normally would.

Does the patient need a home health referral as well?

That is a separate decision for the discharging physician. Home health provides intermittent skilled nursing under its own eligibility rules. A visit from a treating wound clinician is a different service, and many patients have both. Tell us which agency was chosen so orders and updates reach its nurses.

What should I do if follow-up cannot be confirmed before the patient leaves?

Do not list it as arranged. Document the referral as pending, give the patient and family our number and name another clinician who is responsible for wound concerns in the meantime. Make sure active wound orders are in place for whoever is doing the dressing changes.

Related pages

Updated October 2026