Wound Documentation

Cathy Wogamon's picture
Telehealth

By Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN

Wound care has evolved into a massive specialty service in the past few decades, with new treatment modalities, advances in care, and thousands of wound care products. On the forefront of advancements in technology and wound care is a new way to provide care to the patient: telehealth.

Diane Krasner's picture
Wound Care Lawsuits

By Diane L. Krasner, PhD, RN, FAAN

Originally a poster first conceived in 2009, "Six Sticky Wickets That Commonly Occur in Wound Care Lawsuits" is as relevant today as it was a decade ago. In my review of wound care medical malpractice cases, I see these six difficult situations ("sticky wickets") occurring all too often. Strategies for avoiding the Six Sticky Wickets have been updated and are discussed here.

Temple University School of Podiatric Medicine's picture
Temple University School of Podiatric Medicine Journal Club

By Temple University School of Podiatric Medicine Journal Review Club

The advancement of technology and the introduction of the World Wide Web have allowed information to be a click of a button away for health care providers as well as patients. This advancement led to the demand and production of portal devices such as smartphones, which transformed many aspects of society today, including health care. Today, smartphone applications may aid health care providers in drug reference, diagnosis, treatment, literature search, and even medical training. In 2009, an estimated 6.5 million patients had chronic wounds and spent more than $25 billion dollars on wound care. In addition, rising costs of wound management have suggested the need for the use of mobile applications in treatment of wound care patients.

Holly Hovan's picture
Wound Documentation Mistakes

By Holly M. Hovan MSN, RN-BC, APRN.ACNS-BC, CWOCN-AP

Documentation is a huge part of our practice as wound care nurses. It is how we take credit for the care we provide to our patients and how we explain things so that other providers can understand what is going on with the patient, and it is used for legal and billing purposes as well.

Heidi Cross's picture
Risk Factors for Unavoidable Ulcers

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

According to the Agency for Healthcare Research and Quality, more than 17,000 lawsuits related to pressure ulcers (PUs) are filed annually in the United States, second only to wrongful death lawsuits. One of the greatest gifts to defense attorneys was when the Centers for Medicare & Medicaid Services (CMS) published F-Tag 314, finally acknowledging that some ulcers can occur despite best care. The facility essentially can maintain, “Hey, we did everything we were supposed to, and despite that, the patient developed that pressure ulcer”—that is, the ulcer was unavoidable. To prove unavoidability, proper documentation (proof) of best care needs to be in place, as well as documentation that all proper prevention and treatment measures were implemented.

WoundSource Practice Accelerator's picture
Wound Chronicity

by the WoundSource Editors

Chronic wounds affect over 6.5 million people annually in the United States, with a total cost of over $26.8 billion per year. Proper identification of chronic wounds is necessary to develop an effective treatment plan, although many elements—such as intrinsic and extrinsic factors, comorbidities, and mixed etiologies—may complicate this process.

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Cheryl Carver's picture
Case Scenarios: Wound Documentation

By Cheryl Carver, LPN, WCC, CWCA, CWCP, DAPWCA, FACCWS, CLTC – Wound Educator

Auditing documentation has always been part of my wound nurse role in some way or another. My first experience with auditing documentation with a fine-tooth comb was while working in the hospital wound center setting as a hyperbaric oxygen technician. Back then, hyperbaric oxygen therapy was more difficult to get reimbursed, and there were a lot of Medicare appeals. I would search through stacks of documentation to find validation for the diagnosis specific to the hyperbaric oxygen therapy indication. I quickly found out how ONE word determined reimbursement, and we are not talking pennies. The documentation is either there or it isn’t. Wound care documentation also requires the same impeccable documentation. Reimbursement is driven by Centers for Medicare & Medicaid Services (CMS) guidelines. We must follow the rules, or we do not get paid.

Heidi Cross's picture
Legal Issues

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.

Heidi Cross's picture
Legal Issues

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

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

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Cheryl Carver's picture

By Cheryl Carver, LPN, WCC, CWCA, CWCP, DAPWCA, FACCWS, CLTC – Wound Educator