Most of my experience has been in the hospital wound center setting. However, in the last five years you could say I was converted into the long-term care arena, where I felt I could help most from an education and documentation standpoint. I have trained many physicians on how to best document inside the long-term care setting, because of the federal guidelines and annual surveys.

Documentation in long-term care is substantially different from documentation in the hospital, and providers have a higher liability in this setting, given all the wound-related lawsuits. However, the documentation discrepancies can vary. I have given you a few case scenarios in this blog to help define consistent documentation. I have worked on both sides of the fence, so to speak, and have seen the common snags in both settings with documentation with providers and nurses. However, there is also a vast gap in documentation between the wound center and the nursing home. Communication is key when a nursing home patient has weekly visits at the wound center.

Most Common Documentation Errors: Case Scenarios

The medical record is the main source of communication for the clinical team. Wound care documentation must be impeccable for reimbursement of levels of care, procedures, and dressings.

Stage 2 Pressure Ulcer Versus Moisture-Associated Skin Damage

The physician or nurse documents moisture-associated skin damage (MASD) to the sacrum, to avoid documenting an acquired in-house pressure ulcer. The following week during wound rounds, it is noted that the wound has worsened, containing slough. The documentation now tells a different story. It is now a stage 3 pressure ulcer and most likely was indeed a stage 2 pressure ulcer at the date of onset. Wound characteristics and tissue types validate the wound type. You have a patient with a round, partial-thickness wound on the coccyx. The characteristics of the wound being round and the location validate that the wound is primarily caused by pressure. The nurse and physician both document MASD. Why? This will save the facility an acquired in-house pressure ulcer. I have witnessed this throughout the country in long-term care. However, there are instances where the clinician didn't know it was a pressure ulcer, and education is warranted.

Long-Term Care and Wound Center

There is a nursing home patient with a pressure ulcer on the coccyx. The resident is sent out to the hospital wound center every week. The physician debrides the coccyx wound. Nursing home documentation states stage 2 pressure ulcer. The post-debridement note states 10% slough removed, making this wound full-thickness/stage 3. The wound nurse at the nursing home receives the new orders and assessment. The nurse enters the wound measurements and new order but does not notice that the pressure ulcer stage is different. The assessment is often entered into the electronic medical record, put in the chart, or placed in a designated wound progress binder. When the time comes for a chart audit, or maybe when the MDS nurse is entering their data, there will be a discrepancy. The wound is now documented as a stage 3 and appears it has worsened.

Scab Versus Eschar

You have an acquired, unstageable pressure ulcer in a long-term care facility. The treatment nurse documented a suspected deep tissue injury, dry scabbed area, measuring 4 × 4 × UTD. First, a suspected deep tissue injury is essentially a full-thickness wound when looking at the tissue level of destruction. A scab is found on a superficial or partial-thickness wound.¹ This is considered a discrepancy in documentation. A physician has documented, "sharp debridement removing eschar," when it was actually a scab. This is now considered a full-thickness wound, leading to an incorrect billing code. Documentation is critical to ensure accurate reimbursement for the procedures performed.

Partial-Thickness Versus Full-Thickness Wound

A nursing home patient has a skin tear to the right elbow. The nurse practitioner documents: "Wound type as an abrasion, partial-thickness. Tissue types as 90% granulation, 10% slough." This is a discrepancy. There is no granulation or devitalized tissue (slough, eschar) in a partial-thickness wound. This should have been skin tear, full-thickness.

Wound Location

Your charge nurse identifies a pressure ulcer on admission. The nurse documents the left side of the foot. There is an order written for the physician wound group to consult on this resident. The physician now documents the right lateral foot for the wound location. The wrong side and aspect of the foot are discrepancies. There should be an addendum for the correct foot and location.

Conclusion

There is an increase in wound-related lawsuits in every health care setting. Most of these lawsuits are pressure ulcer related: common snags and gaps in documentation, wrong pressure ulcer staging, and implementation of treatment are just a few of the possible causes. Weekly audits of wound care documentation will minimize discrepancies.

Reference

1. Carver C. Knowing the Difference Between Scabs and Eschar. WoundSource. https://www.woundsource.com/blog/knowing-difference-between-scabs-and-e…. Accessed July 24, 2018.

About the Author

Cheryl Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. She currently works as a Clinical Specialist for a leading independent provider of wound care solutions for long term care facilities in the United States, American Medical Technologies a d/b/a of Gordian Medical, Inc. Carver is not only known for her knowledge and expertise, but for enjoying her vocation as much as anyone possibly could. Her strong passion is driven from a life long list of personal experiences as a caregiver. Her mother passed away in in her arms at the young age of 47, due to complications from diabetes, amputation, and pressure ulcers. She now has dedicated her professional career to wound care education in hopes to bolster quality of care and strengthen pressure ulcer prevention. She has received many high reviews from her fellow physician and nurse students from across the country, including but not limited to: plastic surgeons, cardio-thoracic surgeons, general surgeons with wound care experience. Ms. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease specific educational video sessions accessible to employee providers and colleagues.