Wound Documentation

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.

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.

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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.

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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

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Margaret Heale's picture
Standardized Documentation

by Margaret Heale RN, MSc, CWOCN

Wound care can be so straightforward. The process starts with a comprehensive assessment, and then the wound care regimen can be planned and the frequency of dressing changes determined. A well-written order will include all of the relevant components of a wound care regimen listed below:

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Aletha Tippett MD's picture
wound care and legal issues

by Aletha Tippett MD

Medical providers, and especially wound care providers, seem to always be under the looming shadow of lawsuits and legal issues. I have written about this before, but it continues to be an issue as I receive requests for legal reviews repeatedly. I have read many charts for legal reviews, and it actually is very straightforward to avoid or mitigate any legal problems.

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Diane Krasner's picture
wound care documentation

By Diane L. Krasner, PhD, RN, FAAN

Editor's note:This blog post is part of the WoundSource Trending Topics series, bringing you insight into the latest clinical issues and advancement in wound management, with contributions by the WoundSource Editorial Advisory Board.