Facilitating Improved Documentation In Wound Care

Clinical Editor: Kazu Suzuki, DPM

   Having effective and thorough documentation methods can enhance outcomes, improve efficiency and help reduce hurdles to timely reimbursement. These panelists draw on their experience to discuss exactly what one needs to document in charts and how to use technology to make documentation easier.

Q: What are the recommended methods for the wound care documentation?

A: In addition to documenting patient care, Caroline Fife, MD, notes that the medical record supplies information for quality assurance and the data needed to determine the billed revenue for physicians and hospitals. She says any documentation system must be able to document all labs, tests, medications, physical findings and prescriptions. Dr. Fife says many hospitals have converted from paper to electronic medical records (EMRs) that can calculate the physician’s level of service based on the “fields” filled in, according to the 1997 Medicare Documentation Guidelines.

   As Kazu Suzuki, DPM, notes, there is nothing wrong with using paper templates for wound care documentation, especially if one has a low patient volume initially. That said, he says EMR will soon be mandatory in all medical care settings per legislation.

   Most podiatry-specific EMRs have built-in wound care templates, which makes the wound documentation easier, according to Dr. Suzuki. He notes that more sophisticated wound care specific EMRs can extract and sort the data for the purpose of research or as a benchmark against the other EMR users in the rest of the country. Dr. Suzuki’s practice has a computer terminal in each room and he is “impressed” with the use of the Intellicure-brand EMR in his practice.

   Although a good EMR system is ideal for documentation, for physicians who cannot afford the system just yet, Stephanie Wu, DPM, recommends preparing a paper checklist in a SOAP (subjective, objective, assessment, plan) note template that follows Medicare documentation guidelines and using it on every wound patient. Since the documentation should list each wound separately, she recommends describing wounds in a tabular format.

Q: What is the recommended equipment for documentation?

A: “Digital cameras are absolutely necessary for documenting the wounds — before, during and after the wound debridement,” says Dr. Suzuki.

   Dr. Wu’s nurses save the digital pictures onto the computer and print a hard copy for patient charts. She notes that new software and modalities can electronically calculate the size of the wound. For practitioners who cannot afford those modalities, she recommends using an acetate tracing sheet and a wound depth stick to take wound measurements.

   Dr. Suzuki uploads the digital pictures at the end of the day and organizes the pictures into each patient’s electronic folder, treating them as medical records. The more pictures, the better, says Dr. Suzuki, who takes pictures of the wound before and after the debridement from multiple angles at each visit. Sometimes he will take photos during the debridement or take photos of what has been removed from the wounds (i.e., hematoma, eschar, tendon, bone). Dr. Suzuki says this will “tell the story” of what one did in that particular visit.

   As far as the camera’s technical requirements, Dr. Suzuki uses a resolution of 1 megapixel setting. He says this provides sufficient quality for documentation and presentation purposes without taking up too much storage space. Although the brand and type of digital cameras are up to one’s personal preference, he recommends a compact camera with a good “macro” feature, which allows one to take close-up photos.

   Dr. Fife cites advantages to using an EMR designed for wound care since EMR is customized to record the necessary documentation for procedures such as debridement, the application of semi-synthetic skin or to archive photos. She says EMRs with “machine interpretable data fields” are also programmed to determine whether certain procedures are covered for certain diagnosis codes and automatically calculate the level of service for the facility based on the documentation provided.

Q: What should one document and why?

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