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?
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.
Dr. Suzuki says at each visit, one should ask and document the wound pain, which is a vital sign that indicates the status of the wounds being treated, while being the major factor in each patient’s quality of life.
“The rest pain from critical limb ischemia may be mistaken by the patient as wound pain while the neuropathic ‘non-painful’ wound can turn painful when it gets infected,” emphasizes Dr. Suzuki.
Q: What dressings do you use and how do you document them?
A: For most wounds, Dr. Suzuki uses foam dressings as well as “shower-proof” bordered foam dressings. He prefers non-adherent dressings with silicone-based adhesives. Dr. Suzuki says these dressings do not cause additional skin tear upon removal.
He combines the foam dressings with film dressings such as Opsite (Smith and Nephew) or Tegaderm (3M). He secures them with elastic wraps, elastic nets and/or cohesive wraps. Dr. Suzuki also uses alginates for highly draining wounds and hemostasis as well as hydrogel for moistening dry wounds and eschars.
Although physicians know that a moist wound healing environment results in the least painful and the fastest healing results, Dr. Suzuki says there are very few randomized controlled trials on which basic type of dressing facilitates healing better than others. He notes that dressing choice comes down to personal preference, given what is available in the clinical setting.
Occasionally, Dr. Suzuki will use silver antimicrobial dressings including Mepilex AG (Molnlycke), Silvercel (Johnson and Johnson) or Aquacel AG (Convatec). However, when it comes to justifying the cost of silver dressings, he notes an absence of definitive clinical evidence regarding whether silver dressings heal infected or critically colonized wounds faster.
At Dr. Suzuki’s facility, there is a cabinet full of dressing samples and starter kits for the new patients to take home. He says most patients ask for “extra dressings” before he can dispatch a home health nurse or send a Medicare-supplied dressing by a third-payer company.
“These come from the bottom line of your practice but I consider it is necessary as most pharmacies do not carry these specialized wound dressings,” says Dr. Suzuki.
One should document primary and secondary dressings as well as the frequency of change and the duration, according to Drs. Wu and Fife. If the patient gets a new dressing, Dr. Fife says one should state why the patient received a new product. It may be due to maceration, dryness, pain, patient preference, etc.).
Dr. Wu’s center has a list of primary and secondary dressings so the clinician can save time by ticking off what he or she used. This also allows clinicians to track the length of time the patient has been using a specific product.
For example, she says if a patient has been using a particular product for more than four weeks, given that all other factors are well controlled, then the clinician should try another product or an advanced wound healing modality. With this list of dressings, one can also track whether he or she has used the wound product before. With so many dressings to keep track of, Dr. Wu says the doctor can become confused.
Dr. Wu also arranges the delivery of wound products to patient’s homes. The nurse can easily help refill the wound care product (provided that the clinician does not wish to make any changes) based on the tracking sheet of what the doctor previously ordered. She says the tracking sheet also provides documentation of what the doctor has been using so one can continue the same therapy if it is working well for the patient.
Dr. Fife is an Associate Professor in the Department of Medicine, Division of Cardiology at the University of Texas Health Science Center in Houston. She is the Director of Clinical Research at the Memorial Hermann Center for Wound Healing and Hyperbaric Medicine.
Dr. Wu is an Assistant Professor in the Department of Surgery at the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science in Chicago. She is the Director for Educational Affairs and Outreach at the Center for Lower Extremity Ambulatory Research (CLEAR) in Chicago.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.