Eliminating Common Wound Care Documentation Errors

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Eliminating Common Wound Care Documentation Errors
Detailed wound care documentation is a critical
part of day-to-day operations in any wound care
facility. Complete documentation will not only
ensure high-quality patient care but also protect
the practice from litigation. Unfortunately,
lawsuits tied to wound care are incredibly
common. One of the best ways to protect yourself
is to ensure that everyone working at your
facility knows how to document wound care
effectively. In this article, we discussed common
wound care documentation errors and basic
guidelines to eliminate them. Common Wound Care
Documentation Errors To share common wound care
documentation errors we referred
to Medicare claim data. Most of the claims used
two HCPCS codes, A6197 (Alginate or other fiber
gelling dressing, wound cover, sterile, pad size
more than 16 sq. in. but less than or equal to 48
sq. in., each dressing) and A6199 (Alginate or
other fiber gelling dressing, wound filler,
sterile, per 6 inches). The common wound
care documentation errors are as follows Wound
debridement was not at all seen in the
document Debridement, either mechanical or
chemical must be documented as a part of the
wound treatment regimen. Those in podiatric
medicine, especially those who dispense wound
dressings, always document debridement. If you
are treating wounds routinely without
debridement, this falls below the standard of
care for wound treatment.
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Eliminating Common Wound Care Documentation Errors
Wound evaluation missing Wound evaluation
missing type, location, size, depth, and/or
drainage amount. These simple and obvious
findings should be recorded whether you are
dispensing dressings or not. The simple wound
template can assure that these basic clinical
findings are recorded. As it is the case that
wound/surgical dressings are reimbursable only if
the wound is a full-thickness wound, it goes
without saying that the depth and staging must be
recorded. Not detailing characteristics of the
wounds In the era of EHR, there is simply no
excuse for not templating and documenting the
characteristics of the wounds. In some podiatry
practices, paper templates are still used in the
treatment rooms which are partially completed by
staff and partially by the physician. These
templates are then shared with a documentation
scribe who then converts the templates into the
medical record. If the characteristics of the
wound or if the size, depth, and staging are
missing for some reason, the scribe hands the
template back to the physician to complete.
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Eliminating Common Wound Care Documentation Errors
Not mentioning the quantity The order did not
specify a quantity to be used at one time. This
is information that should be recorded both in
the patients medical record and in the detailed
written order (DWO) and is no different than what
is required in writing a prescription for an
antibiotic or any other prescription product.
Simply recording the information in a detailed
written order and not having identical
information documented in the medical record will
undoubtedly result in a claim rejection if your
claims are subject to a complex medical review.
The bottom line is, insurance carriers want you
to simply document how many wound dressings you
think the patient needs. Not specifying dressing
change frequency This information should be
recorded in the patients medical record and in
the detailed written wound dressing prescription
order described above. In most cases, the order
should indicate that the patient is to change the
dressing 1 time per day (collagen
powder/alginate) or 1 time every 3 days (foam).
Again, this should be templated on the detailed
written order form embedded into your EHR.
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Eliminating Common Wound Care Documentation Errors
Eliminating Common Care Dressings Documentation
Errors Measure consistently Use the body as a
clock when documenting the length, width, and
depth of a wound using the linear method. In all
instances of the linear (or clock) method, the
head is at 1200 and the feet are at 600. When
measuring length, the ruler will be placed
between the longest portion of the wound between
1200 and 600. The width is measured at the
widest part of the wound between 300 and 900.
Measuring depth is a little more challenging.
This can be accomplished by gently placing a
cotton-tip applicator into the deepest part of
the wound, then holding the applicator up to a
ruler. This same applicator can be used to
measure tunneling and undermining. Because
undermining spreads in many directions, the
linear method should be used to document multiple
measurements. For example, a nurse may describe
the wounds undermining as 0.5 cm between 100
and 200 and 1.5 cm between 200 and 500. Be
specific Always be specific while documenting
and use exact keywords explaining the clinicians
treatment. The term packed is a common example
of a wound assessment documentation term often
used in healthcare facilities and in the
courthouse. If a wound gets worse or fails to
heal, lawyers may argue that the clinician packed
the
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Eliminating Common Wound Care Documentation Errors
wound too tightly, causing additional damage.
Instead of using the word packed, a more
accurate wound care charting sample would say,
filled the wound loosely. This type of
specificity leaves less room for
misinterpretation and accusations of
wrongdoing. Grade appropriately Edema, or
swelling, can vary in severity depending on the
patient and the wound. Some will experience
significant swelling, while others may have
little or none. Edema can be documented using a
simple, yet effective, grading system that rates
its severity on a scale of one to four. To use
this system, healthcare professionals must apply
pressure to the affected area for five seconds,
then release it. The grade of the edema is
determined by the depth of the depression that is
left grade one indicates a 2-mm depression that
rebounds quickly, grade two describes a 4-mm
depression that takes a few seconds to rebound,
grade three pertains to a 6-mm depression that
lasts for 10 to 12 seconds, and grade four
signifies an 8-mm depression that lasts for 20
seconds.   Wound care documentation has the power
to elevate your practices standard of care and
protect your team from undue legal
charges. Medical Billers and Coders (MBC) is a
leading medical billing company providing
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Eliminating Common Wound Care Documentation Errors
complete billing and coding services. For
provider education, we shared common wound care
documentation errors and guidelines to eliminate
them. If you are looking for medical
billing assistance for your wound care practice,
email us at info_at_medicalbillersandcoders.com or
call us at 888-357-3226.