Up to 20% of all US medicolegal claims and more than 10% of settlements are wound related.¹ Documentation is essential for all health care settings; however, there are differences in each setting. Knowing your clinical setting’s requirements from a documentation standpoint is critical in meeting documentation needs. Every setting has policies and procedures for skin and wound care that reflect current clinical and operational guidelines approved by the facility. Facilities should consider standardized workflow to provide a systematic process to capture, generate, track, store, retrieve, and retain documents of the medical record. These clinical workflows should be reviewed and updated routinely to avoid denial of claims based on missing documentation elements.^2,3

Documentation Requirements by Setting

Long-Term Care Wound care documentation in the long-term care setting is a critical component of resident care. It is stated by the Office of the Inspector General of the US Department of Health and Human Services that providers carry the burden of proving that care was actually rendered to the patients (residents).⁴

The documentation must reflect the standards specifically found in Section 483.25 Appendix PP of the State Operations Manual for multiple F-tags in regard to quality of life, treatment or services to prevent or heal pressure injuries, and addressing minimum assessment, daily monitoring, and documentation requirements for any skin ulcer or wound.⁵ Documentation standards are based on these guidelines; however, taking photos of wounds relies on each individual facility’s policies and procedures because facilities may have different policies on whether images can be included in documentation.

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Outpatient Care

Outpatient wound care centers and multifacility organizations’ rules and regulations are guided by documentation and billing that are generated from Medicare Administrative Contractors, National Coverage Determination, Local Coverage Decisions, Centers for Medicare & Medicaid Services, and The Joint Commission, among others. In outpatient care, as in all settings, documentation should contain clearly recorded evidence of the wound assessment, wound progress, response to treatment at each visit encounter, wound images, and debridement services.⁶

Goals of Documentation

The goal of documentation is to capture clinical specifics with accuracy to reflect medical necessity for services rendered for billing and reimbursement and to communicate with the wound care team. Whether the provider or clinician is working in the hospital, long-term care, acute care, or home health setting, there are documentation standards that need to be met to support patient care. Customized databases for specific health care settings will help identify and include all codes that represent the diagnosis, evaluation and management service, procedure, and products used by the health care facility or agency.^2,3

Documentation in the Electronic Medical Record Workflow

The workflow of the electronic medical record (EMR) can help make sure you are creating comprehensive documentation. Descriptive documentation should reflect the wound status. A variety of information must be completed by the provider and/or clinician. These sections should be accurately completed to validate quality of care and medical necessity. The workflow components of the wound care EMR should include:

• Chief complaint: Reason for the patient’s visit, detailed history, and physical data⁶
• History of present illness: Key element of medical necessity and objective information for the practitioner to review while reviewing symptoms and performing a physical examination⁶
• Past medical, family, and social history – Chronic illnesses, medications, allergies, tests, laboratory results, and activities of daily living⁶
• Review of systems or current procedural terminology (CPT®) as an inventory of body systems⁶
• Physical examination: Focused on the skin and or wound condition⁶; and wound location, measurements, wound tissue, pain, nutrition, support surfaces, preventative measures, physician or family notification, treatment, risk status, and whether wound was after admission or present on admission⁷
• Assessments and supplemental screening tools6: Skin and wound assessment, risk assessment,⁶ moisture management, and change in clinical or wound status⁸
• Procedures performed: Consent for procedure, time-out parameters, debridement, biopsy, etc.⁶
• Ordering supplies and tests⁶ and use of durable medical equipment or dressing⁸
• Patient education: Evaluated on an individual basis for effectiveness⁶
• Plan of care: Treatment goals and provider follow-up⁶
• Patient discharge instructions and summaries: Discharge summaries with treatment instructions provided to patients; documents generated from the clinical workflow and reflecting the visit encounter; internal and external documentation audited by clinician to measure documentation compliance⁶

Consistency in wound care documentation is essential in preventing litigation, supporting reimbursement claims, and communicating among health care professionals. Documentation takes time, coordination, and effort from all team members to uphold the care performed. The EMR helps bolster team communication, support critical pathways, provide a safety net, and validate contract fees with payers. Ongoing education of wound care competency is one way to improve the clinician’s knowledge, increase patient satisfaction, increase clinician satisfaction and retention, and improve facilities’ public relations.³

Conclusion

Clinical documentation serves as a way to capture patient care from the time of admission to discharge in any health care setting while communicating with the team through the EMR. However, clinicians should be familiar with the standards for the specific setting they work in as a foundational step to good documentation. This is critical in providing continuity of care for patients. Documentation should be complete, detailed, and accurate to best communicate among health care professionals and to prevent ambiguity from a legal standpoint. The EMR workflow can help assist in making sure that all standards are met according to regulatory standards. Meeting standards will help prevent litigation, support reimbursement, and ensure patient care outcomes.

References

1. Pfaff J, Moore G. ED wound management: identifying and reducing risk. ED Legal Letter. 2005;16:97-108.

2. Hess CT. Auditing wound care documentation. Adv Skin Wound Care. 2015;28(5):240. doi: 10.1097/01.ASW.0000464707.80878.68.

3. Hess TS. The art of skin and wound care documentation. Adv Skin Wound Care. 2005;18(1):43-53.

4. Office of Inspector General. Medicare fraud strike force. https://www.oig.hhs.gov/fraud/strike-force/. Accessed January 21, 2021.

5. Centers for Medicare & Medicaid Services (CMS). State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities. Revised November 22, 2017: Woodlawn, MD: CMS; 2017:248-266, 272, 273.

6. Hess CT. Wound care medical record documentation. Adv Skin Wound Care. 2018;31(10):479. doi: 10.1097/01.ASW.0000546121.09810.83.

7. Berlowitz D, Parker V, Niederhauser A, et al. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/publications/files/putoolkit.p…. Accessed January 21, 2021.

8. Lyder CH. Regulation and wound care. In: Baranoski S, Ayello EA, eds. Wound Care Essentials: Practice Principles. Springhouse, PA: Lippincott Williams & Wilkins; 2004:35-46.