Electronic Medical Records

Benchmarking: Benchmarking is using published wound outcomes reported by others as a framework within which to assess your facility’s outcomes and potential need for improved care.

Chronic wound: A chronic wound is a wound that has failed to progress towards healing in 30 days or more. There are varying factors that can cause a wound to stall, such as infection or a prolonged inflammatory phase. It is important to document the wound’s progress, any stalling factors, and interventions put into place to restart the healing cascade.

Digital wound measuring tool: Digital wound measuring tools include devices that may provide two- or three-dimensional assessment (length, width, depth, surface area) of a wound with electronic medical record software integration and may not require physical contact.

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. 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.).

Up to 20% of all US medicolegal claims and more than 10% of settlements are wound related. 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.

Continuity of care has always been the heart of practicing medicine and is especially important for wound care. Continuity of care in wound management equals better outcomes, cost-effectiveness, and satisfaction rates from patients. In providing continuity of care, wound care providers face challenges of time constraints to become acquainted with their patient and to build a rapport while simultaneously learning about their patient’s wound history. The electronic medical record (EMR) is vital in supporting continuity of care. These platforms enable the medical record to be in a central place for providers and clinicians to access, modify, and use to communicate about their patient’s progress.

Paula Erwin Toth, RN, MSN, FAAN, WOC nurse

Northeast Ohio is now being enveloped by a polar vortex. The subzero temperatures put everyone at risk, but our patients with chronic wounds are especially vulnerable. Neuropathy can desensitize them to the cold and result in frostbite, inadequate shelter and heat, and an inability to go to health care appointments, shop for food, or pick up (or even afford) prescriptions and wound care products. This can have devastating effects.

by Rafael Mazuz

Computer vision, machine learning, Electronic Medical Record (EMR) integrations, clinical decision support -- a new class of digital health technologies are transforming the practice of advanced wound care. In this article, we’ll explore the significance of this relatively new yet crucial dimension for wound care stakeholders by focusing on four major categories:

by Heidi H. Cross, MSN, RN, FNP-BC, CWON

Part 2 in a multi-part series looking at the basics of avoiding litigation as a health care provider. Read Part 1 Here.

By Jeffrey Levine MD

Pressure injury prevention and management are sometimes overlooked in the hospital setting, where the focus is generally on acute illness. Given the immense implications in terms of cost, complications, reputation, and risk management, it is in the interest of all facilities to maximize quality of care with regard to wounds. This post will offer some suggestions on how this can be accomplished in hospitals by tweaking the system for maximum quality.

By Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Substandard documentation tops the list of mistakes for long-term care facilities. It involves "all hands in the chart" so to speak. This encompasses all disciplines, from the nursing assistant to the physician. Discrepancies and gaps in documentation put your facility at risk of litigation. Impeccable documentation is essential in defending any case. Your facility must have a "safety net" in place. This "safety net" consists of educating staff about the importance of timely and detailed documentation not only for the facility, but for their license. Often times, clinicians are not aware of the legal repercussions of their actions. Surveyors will also consider other related Federal Tags (F-Tags) during investigations for compliance.

By Janis E. Harrison, RN, BSN, CWOCN, CFCN

As I was pushed from the room where my husband was coding, I was met by a tiny little nun, we'll call Sister. She tried to move me to a waiting area nearby but I knew I was not going to step away from the door. They had not listened to or assessed my husband during a very concerning time and he was supposed to be in post-op recovery.