Declaration Of D Statutory Requirements For Wound Care Management And Sharp Debridement Endorsements 701 683053

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Occupational Therapy Credentialing
P.O. Box 47877
Olympia WA 98504-7877
360.236.4700

Declaration of Completed Statutory Requirements
for Wound Care Management and Sharp Debridement
Endorsements
Please complete this form and return it directly to the address above.

1. Declarant (print or type clearly)
Name:
WA State license # (if Applicable):

Birth Date:

Address:
City:

State:

Zip:

You must sign and date this declaration in order for the Department of Health to
process and approve the declaration. Please carefully read and check all boxes
applicable to you and then sign and date the last page.

2. Endorsement through certification
FF Endorsement through Certification as a Certified Hand Therapist or
Certification as a Wound Care Specialist (satisfies both wound care
management and sharp debridement)
The marked check in the box above demonstrates that I possess certification
as a certified hand therapist by the hand therapy certification commission; or
certification as a wound care specialist by the national alliance of wound care,
or equivalent organization approved by the Board of Occupational Therapy.

DOH 683-053 November 2011 									Page 1 of 3

3. Wound care management endorsement
FF Wound care management endorsement through clinical education and
training
The marked check in the box above demonstrates that I have successfully
completed at least fifteen hours mentored training in a clinical setting which
included observation, cotreatment, and supervised treatment by a licensed
occupational therapist authorized to perform wound care management under
Chapter 18.59 RCW or by a licensed health care provider authorized to perform
wound care management in his or her scope of practice. I hereby certify that the
clinical training received included a case mix similar to my expected practice.
“Wound care management” means a part of occupational therapy
treatment that facilitates healing, prevents edema, infection, and
excessive scar formation, and minimizes wound complications. Treatment
may include: assessment of wound healing status; patient education;
selection and application of dressings; cleansing of the wound and
surrounding areas; application of topical medications, as provided under
RCW 18.59.160; use of physical agent modalities; application of pressure
garments and nonweight-bearing orthotic devices, excluding hightemperature custom foot orthotics made from a mold; sharp debridement
of devitalized tissue; debridement of devitalized tissue with other agents;
and adapting activities of daily living to promote independence during
wound healing.

4. Sharp debridement with a scalpel endorsement
FF Sharp debridement with a scalpel endorsement through clinical education
and training
The marked check in the box above demonstrates that I have marked the box in
paragraph three above and have additionally completed a minimum of:
A.
B.
		

two thousand hours in clinical practice, and
fifteen hours of mentored sharp debridement training in the use of a 		
scalpel in a clinical setting.

I certify that my mentored training included observation, cotreatment, and
supervised treatment by a licensed occupational therapist authorized to perform
sharp debridement with a scalpel under Chapter 18.59 RCW or by a licensed
health care provider authorized to perform wound care management including
sharp debridement with a scalpel in his or her scope of practice. Both the two
thousand hours in clinical practice and the fifteen hours of mentored training in
a clinical setting included a case mix similar to my expected practice.
“Sharp debridement” means the removal of loose or loosely adherent
devitalized tissue with the use of tweezers, scissors, or scalpel, without
any type of anesthesia other than topical anethestics. Sharp debridement
does not mean surgical debridement.
DOH 683-053 November 2011 									Page 2 of 3

I declare under penalty of perjury under the laws of the State of Washington
that the foregoing is true and correct. Furthermore, my signature below
acknowledges that I have reviewed Chapter 18.59 RCW and that I satisfy the
requirements contained therein.

Declarant
Date (mm/dd/yyyy)			

Place of Signing

DOH 683-053 November 2011 									Page 3 of 3
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Title                           : Declaration of Completed Statutory Requirements for Wound Care Management and Sharp Debridement Endorsements
Creator                         : Washington State Department of Health, Health System Quality Assurance, Office of Customer Service
Description                     : A form for health professionals to endorse to become a Certified Hand Therapist or Cerification as a Wound Care Specialist.
Subject                         : Board of Occupational Therapy, Declaration of Completed Statutory Requirements for Wound Care Management and Sharp Debridement Endorsements, Certified Hand Therapist, Cerification as a Wound Care Specialist, form, endorsement, Sharp Debridement Endorsement
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