In the history portion of your chart note, continue to list the onset of the ulcers, possible precipitating factors/trauma, previous treatments rendered, etc. Also include in your charting comorbidities, such as peripheral vascular disease, neuropathy, metabolic conditions and immunocompromised states, that may impact healing.
In your chart, there should be documentation of the measures you took to address any risk factors. Indicate additional diagnostic testing done/anticipated (such as bone scan/magnetic resonance imaging for possible osteomyelitis). Note other specialist consultations (such as vascular evaluation for a non-healing ulcer, infectious disease consult for antibiotic therapy modifications, etc). Document offloading measures, patient/family discussion regarding adherence, etc.
In the examination portion of your chart note, you should list the location of each ulcer(s), size of the ulcer(s), description of the ulcer base, drainage, odor, surrounding cellulitis, etc. Hopefully as the wounds improve, your chart note will reflect these changes or document any deterioration of the condition.
In the treatment portion of your chart note, be sure to note what specific type of tissue you debrided. Clearly document whether you debrided skin versus subcutaneous tissue versus muscle versus bone from a wound(s) to qualify for the use of that debridement code. As the ulcer improves, the type of tissue and therefore choice of debridement codes should reflect this as well.
As always, be careful in the use of templates when you document. Simply “cutting and pasting” portions of the previous chart note without documentation of findings/changes specific to that date of service may result in a poor quality chart note. Accordingly, the information listed may not validate your findings and treatment decision for that day. This applies to both a billing perspective as well as a medical-legal perspective.