Wound Documentation

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Patients with wounds are cared for according to the scope and standards of practice, which are used to guide nurses and other members of the interprofessional wound care team. An intricate network of physicians, medical researchers, government regulators, and medical journal contributors helps develop the standard of care. Standards are not enacted like laws; rather, they arise naturally as a result of research investigations, existing physician practices, and technological advancements. Standard of care in the health care profession is sensitive to time, place, and person. The wound care standard must be carried out in accordance with accepted wound treatment standards that are evidence based.

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Wound documentation is critical for the delivery of effective wound care, the facilitation of care continuity, and proper health data coding. Inaccurate wound documentation can impact the ability to determine the best wound treatment options and the overall wound healing process. Unfortunately, almost half of all medical record notes on wounds lack key details on assessment and intervention in some settings.

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By Girisha Maheshwari, Pavan Mujawdiya, and Shivani Gupta

Chronic wounds and their management pose a serious challenge to clinicians worldwide and are one of the major public health challenges faced by developing countries. Worldwide, over 40 million people develop chronic wounds, which adversely affects their quality of life. However, epidemiological studies concerning chronic wounds and their management are limited, especially in developing countries. According to the largest community-based epidemiological study on wounds in India by Gupta et al., the estimated prevalence of chronic and acute wounds is 4.48/1000 and 10.5/1000 in India. This study is more than a decade old, and there is no recent data available in the public domain. The lack of organized wound data makes it difficult to formulate new therapeutic strategies, create effective health care policies, or offer efficacious treatment options. Complex wounds take time to heal, and if they are not identified at the earliest stage, the treatment process may be complicated.

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By Heidi Cross, MSN, RN, FNP-BC, CWON

Since the advent of coronavirus disease 2019 (COVID-19), I haven’t done much flying, but I love travel and I love flying. One of my favorite experiences is a window seat at about 30,000 feet on a clear sunny day. The views can be spectacular – whether flying across the Rockies or the Plains or any of the stunning and varied scenery of this country or the world. A couple of my most memorable flights involved flying into New York City with views of the New York skyline with Lady Liberty in clear sight, or into Washington, DC with clear views of the Mall, the Jefferson Monument, and the Capitol. The Alps and the Rockies are incredibly awe-inspiring, beautiful, and breathtaking. From there, you get a good overall picture of the landscape.

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When assessing and documenting a wound, it is important to note the amount and type of wound exudate (drainage). Using our senses is a large part of the initial wound assessment, followed by accurate documentation. Wound exudate or drainage gives us significant information about what is going on with the wound, all the way down to a cellular level, and it is one of the wound components that guide our topical treatments. As mentioned in prior blogs, a dry cell is a dead cell, but a wound with too much moisture will also have delayed healing. Additionally, infection, poor nutrition, impaired mobility, impaired sensory perception, and even malignancy in the wound can impair the healing process.
In acute wounds, drainage typically decreases over several days while the wound heals, whereas in chronic wounds, a large amount of drainage is suggestive of prolonged inflammation with failure to move into the proliferative phase of wound healing. An increase in drainage with malodor can be an indication of infection and should be treated appropriately based on the overall picture and goals of wound care.
There are many different types, consistencies, colors, and characteristics of wound drainage. In this blog, we discuss the most common types and what they could mean.

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Wound photo documentation captures a visual reference and helps provide a timeline for healing status for the patient’s medical record. Pictures in wound care can be used to ensure accuracy of measurements, to encourage objective assessments, to reduce the risk of misinterpreting the cause of the wound, as a teaching resource to both patients and new clinicians, and to encourage the use of evidence-based practices. In providing wound care from a distance such as through telewound services, wound photos are taken to help in diagnosis and treatment. The quality of the photo may vary depending on the person taking the photo (clinician, caregiver, patient). However, the emphasis is on using the photo in conjunction with the patient’s clinical wound descriptions and medical history, thereby evaluating the wound, treatment plan, and healing progress. Clinical documentation is a legal, moral, economic, and professional responsibility. Wound photos supplement the written record but should never replace it. Despite the value of wound photography, not all health care settings provide wound photo documentation software or include this as a part of their wound care policies and procedures. The facility or agency should always discuss this issue with the risk manager or legal counsel because each state has its own rules on the use of images.

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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.

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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. 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.).

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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.

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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.