Facilitating Improved Documentation In Wound Care

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Clinical Editor: Kazu Suzuki, DPM

   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?

A:All panelists say one should note the wound’s size and depth in centimeters. Dr. Wu also advises documenting the percentage of granulation tissue, fibrotic tissue, eschar, necrotic tissue, type and amount of exudate, odor, periwound edema, erythema and maceration (in cm). One should include a neurological and musculoskeletal section if appropriate.

   As part of the SOAP template, in the subjective section, Dr. Wu documents changes in medication and any changes since the last visit. These changes may include hospitalizations or other doctor visits. She also notes pain, blood glucose (if applicable) and tolerance of wound dressings. Dr. Wu says having a detailed subjective section will tie in well with an evaluation and management (E&M) report.

   In the objective section, Dr. Wu notes the patient’s vascular status, Doppler pulses, edema (pitting/non-pitting) and skin temperature. She recommends assessing vascular status at every visit, especially in the diabetic population. Dr. Wu says it is not unusual to see digital ischemic changes from one visit to the next that are secondary to possible emboli.

   In the plan section, Dr. Wu documents the type of debridement. Dr. Suzuki adds that he documents the instruments he uses for debridement and the depth of tissue he has removed. Debridement documentation requirements may include a description of the wound before and after the procedure as well as the type of tissue one has removed, according to Dr. Fife. She says some regional carriers specify what must be included in the debridement note.

   Dr. Wu also notes that one should document the type of anesthetic used and the type of hemostasis used if such categories are appropriate. Physicians should also document the type of wound care product they use (including the frequency of change and duration of therapy) and the type of compression dressing, if appropriate.

   She advises noting the prescriptions one dispenses and noting for the record that you instructed the patient to watch for signs and symptoms of infection.
   Dr. Suzuki adds that for a wound care practice, one will be prescribing a lot of antibiotics and pain medications. Physicians may also be providing wound care instructions for the home health nurses.

   Dr. Wu says insurance companies often request physicians either to write a letter or submit previous notes for the approval of advanced wound healing products. Having a detailed note helps improve the chances of getting insurance company approval for these products, according to Dr. Wu. In the same vein, Dr. Fife emphasizes documenting dressing products, including the plans for the frequency of dressing changes and the duration of these orders.

    “Good documentation of your ongoing treatment and the dressing regimen helps other clinicians treat your patients in your absence,” says Dr. Suzuki.

   In addition to the wound depth and size, Dr. Fife suggests documenting wound undermining and tracts in centimeters. She says one should also describe the wound bed and the periwound skin. Dr. Fife also notes the granulation, slough, eschar and epithelialization of the wound with assessment in the percentage of wound surface area. The physician can classify drainage by its amount and character, and assess the patient’s pain.

   Dr. Suzuki follows the Medicare Local Coverage Determinations (LCD) guideline. This guideline includes noting the presence/absence of non-viable tissues and signs of infection (erythema, edema, odor) for each visit. If something is influencing the wound healing process (such as poor diet, non-compliance, home nurse issues, etc.), he says one should document that as well.

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