Analyzing Your Technology to Meet Wound Care Documentation Requirements
by Lindsay D. Andronaco RN, BSN, CWCN, WOC, DAPWCA, FAACWS
Patient safety is always of the utmost importance. Health care providers aim to improve the health of others. Having been in many settings during my career, I have been privileged to see the transition of how nursing has changed due to technological advances. Long gone are the days sitting in rural Vermont trying to decipher handwritten orders, counting drips on a dial control IV set and doing pediatric drug calculations while a parent hovers over you. Luckily, we have made strides to eliminate such frustrations, ways of frequent error, and time consuming tasks. Nursing has been forced to evolve as technology evolves.
How Technology Has Evolved Health Care
Internet-based drug guides, being able to share research and access it with a few clicks, and even refreshing yourself on a procedure you have not done in quite some time via the internet makes nursing actions faster and allows the clinicians to get back to other tasks. This technology transformation is both positive and negative. The initiation of the EMR, MAR integrated with the Pyxis machines, and recently CPOE have transformed nursing for the better. We have become more JACHO and CMS compliant. Although these advances are not perfect, they have decreased the frequency of errors that were being made a decade ago.
Yet, as much as we rely on computers and they assist with our daily nursing duties, we still have to keep our nursing assessment skills and not just click a box to carry a field forward. This is most frustrating in wound care. Wound measurements, staging, or dressing orders are carried forward without accurately seeing if it matches the clinical presentation in front of you. In particular, pressure ulcers are an issue that is looked at with scrutiny by CMS. If the nurse or provider does not document that the pressure ulcer was present on admission, the entire care of that ulcer during the admission is not reimbursed. It is essential to document what you see in the EMR.
Pressure Ulcer Documentation Requirements and CMS Billing Criteria
I would suggest that in your practice, you analyze what technology you have for your clinic or hospital, and you ensure that your EMR workflow meets guidelines. Most independent hospital programs, specifically those that are all dictation based, have had difficulty meeting the billing criteria. For example, if not all fields are created or filled out, you may not meet the criteria for an application for a cellular and/or tissue-based product (formerly skin substitutes) and therefore may not be reimbursed. Addressing education, pain, nutrition, and hand off of information to the SNF/VNA are also necessary and being required by CMS as an all-inclusive medical picture of the care provided. In addition, the codes for billing depend on the documentation and if the LCD documentation requirements are not met, you may be denied your payment.
McCullough, B. (2011). Shands at The University of Florida – Drugs and therapy bulletin. Medication Safety – If to err is human, is CPOE divine? Vol 25, 7, p. 1-6. Retrieved June 3, 2014 from: http://professionals.ufhealth.org/files/2011/11/0711-drugs-therapy-bulle...
Wakefield, M. K. (2008). The Quality Chasm series: Implications for nursing. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Vol. 1, pp. 47–66). Rockville, MD: U. S. Department of Health and Human Services. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/WakefieldM_QCSIN.pdf
About the Author
Lindsay (Prussman) Andronaco is board certified in wound care by the Wound Ostomy Continence Nursing Certification Board. She also is a Diplomate for the American Professional Wound Care Association. Her clinical focus is working with Diabetic Limb Salvage/Surgical/Plastic Reconstruction patients, though her interests and experience are varied and include surgical, urological and burn care, biotherapeutics and Kennedy Terminal Ulcer research. Lindsay is the 2011 recipient of the Dorland Health People's Award in the category of 'Wound Ostomy Continence nurse' and has been recognized in Case In Point Magazine as being one of the "Top People in Healthcare" for her "passionate leadership and an overall holistic approach to medicine."
Lindsay is board certified in wound care by the Wound Ostomy Continence Nursing Certification Board. She also is a Diplomate for the American Professional Wound Care Association. In 2011, Lindsay was honored with the Dorland Health People's Award in the category of 'Wound Ostomy Continence nurse.'
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.