By Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWCN-AP, CWS, RNFA
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Multiple electronic medical record (EMR) systems are being utilized across the health care spectrum. However, these systems do not always contain documentation elements that capture specialty care such as wound care. Workflow and synchronization within the EMR are necessary to manage and support good wound care outcomes.
When setting up the EMR system at your facility, consider documentation elements such as built-in templates, algorithms, and designs that are being used in the workflow analysis.1 Regulations should guide your decisions in this process because not all health care settings have the same requirements (outpatient wound care clinics, long-term care, home health care, etc.).
A workflow is an organized and repeatable process for assessing a patient, planning and executing treatment, and documenting all care provided to the patient. The EMR workflow includes structure or work system features and processes that support care and can be customized to match your wound care setting. The key to a successful EMR is conducting a workflow analysis. The workflow analysis evaluates current processes, including data flows, gaps in best practice, and collaborations with clinical team members.2 Specialized wound care documentation systems are designed according to the workflow and particular practice. The workflow may include options such as scheduling, role-based workflows, analytics, secure email, facility level of care, quality indicators, audit trails, and various reports that can be generated, such as benchmarking.2
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Clinicians should have practical knowledge about how to use their EMR correctly to ensure that workflow is streamlined. Wound care documentation within the EMR can identify gaps in practice, optimize documentation standards, meet billing and reimbursement needs, and improve collaboration within the clinical team.
For example, wound care clinics that utilize a specialized EMR know the value of workflow. On a typical workday, there are various levels of care (new patients, follow-up visits, hyperbaric oxygen evaluations or treatments, and nurse visits). Scheduling can be extra challenging depending on which physician is working on what day, staffing, and coordination of care (transported by cot, wheelchair, etc.) From the time the patient checks in to discharge from the visit, the wound care staff is documenting in the patient’s EMR to prove the full scope of diagnosis and treatment for the wound care patient’s visit encounter. Particular wound care elements are built into the specialty EMR. The EMR workflow is designed to streamline all of these services while being compliant with all aspects of documentation standards from a quality of care and billing standpoint.
Wound care in Long-Term Care Facilities
The EMR workflow for a long-term care facility would be different, but no less important. Long-term care facilities tend to be under the microscope, and documentation must be impeccable, especially in wound care, where legal cases often develop. These types of facilities normally use a custom-designed template within the EMR to provide simpler workflow for the wound assessment. The template can be designed to alert users of errors or incomplete sections while moving the clinician through the workflow to completion. The user will become more confident in time and find it simpler to assess wounds from a documentation standpoint.
Wound assessments in any setting should always be as thorough as possible and include detailed notes. Depending on the facility policies, photos of the wound may be included to supplement documentation; however, photos are not a replacement for thorough assessment notes.
Proof of Medical Necessity
Wound care documentation must also reflect medical necessity from a billing standpoint. The workflow within the EMR can assist in validating that criteria were met for reimbursement regarding durable medical equipment, procedures, and visits, etc. Physician evaluation and management are streamlined, with little to no room left for errors and omissions.2
It is critical to make sure that your workflow meets your health care setting needs and that staff members using the documentation system are well trained. Taking steps up front to make sure that the EMR system is correctly configured and that staff members are appropriately trained will in return save time and lessen errors. Data collected are imperative in enhancing clinical pathways, validating payers and reimbursement, improving provider satisfaction, and therefore increasing consistent quality of care and optimizing outcomes.
1. Berner ES. Clinical Decision Support Systems: State of the Art. Rockville, MD: Agency for Healthcare Research and Quality; 2009.. https://digital.ahrq.gov/sites/default/files/docs/page/09-0069-EF_1.pdf. Accessed January 21, 2021.
2. Hess CT. Value of a specialty wound care electronic medical record. Adv Skin Wound Care. 2013;26(1):48. doi: 10.1097/01.ASW.0000425941.32993.32.
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.