Instructions
Take Another Course
|
•
Goals of Wound Care
The overall goals of proper wound care and its documentation include assuring a high quality of care, positive clinical outcomes, positive financial outcomes, and a high level of patient satisfaction. There have been extensive efforts to assist physicians, nurses, and others to gain more training as they specialize in wound care. And, with home health therapy for wound rehabilitation connecting to patient characteristics more than number of visits, communication through proper documentation is crucial to assuring these outcomes. Whether the patient is transferring from one care setting to another, such as from inpatient care to outpatient care, clear communication through complete medical record documentation helps to assure the appropriate continuation of care for positive clinical outcomes. Both positive clinical outcomes and appropriate documentation to achieve accurate reimbursement will affect financial burden for the patient and for the health care system. Patient satisfaction relies on positive clinical and financial outcomes. Wound care providers and support personnel are responsible for providing documentation to assure that patients do not have to face a severe financial burden in order to pay for essential surgical dressings that should be covered through Medicare or healthcare reimbursement systems. Increased financial burden for patients may lead to barriers that impede adequate care and treatment, worsening the prognosis for wound healing.
A 2016 article in the journal “Skin & Wound Care” by Kathleen Schaum brought home this point with the following anecdote. “Healthcare practitioners should make a goal of never making the patients pay 100% for their essential surgical dressings when they should pay only 20%. Personally speaking, I know for sure that my mother would stop using her surgical dressings if she had to pay 100% of the costs. She is 98 years old, has paid into Medicare Part B for many years, and deserves to receive those benefits now, when she needs them most.” Proper wound documentation can help keep reimbursement at its maximum level for patients like these.
The Importance of Documentation Now we can discuss why documentation is especially important in the care and treatment of wounds. First, objective documentation of the wound is required to generate and monitor a wound management plan and, as treatment progresses, to determine if their treatment is clinically-, and cost-, effective. Documentation is used to create a baseline and evaluate any progress in wound healing (or the non-progression of wound healing). Any stalls in wound healing, such as infection or the patient’s ability to adhere to recommended wound care, are documented to allow the team to adjust care plans and work toward patient-centered care.
When to Document Documentation should include initial intake, daily or routine notes according to facility protocols, and weekly/monthly reports for coverage submissions. In addition, documentation should also include any notifications from the physician, changes in plans, the implementation of new plans, or any reasons that plans may not change. Any education provided, signs and symptoms, and responses to treatment should be documented routinely. And, especially for wound care and treatment coverage, justifications for treatment and changes to that treatment, supplies and changes in supplies, and any needs for referrals should be documented.
General Requirements for Documentation Medical records provide the opportunity to communicate and document several specifics. The list below is based on the documentation required to justify medical necessity, and ultimately coverage, for the care and treatment of chronic wounds. A diagnosis and description of the duration, clinical course, and prognosis of the wound are foundational pieces of information. We will look at some of the specifics for this documentation in later slides. It is also important to document other conditions and treatments that might affect past or current wound healing. This may include treatments for additional diagnoses, such as diabetes. To provide justification for wound care supplies, all medical records and reimbursement submissions must include detailed written orders and a clinical point of care that aligns with coverage guidelines. Any other information that is helpful in supporting medical necessity for the appropriate treatment care plan and supplies should be included in the medical record and in submissions for coverage.
|
.h1.jpg)
.h3.jpg)
.h4.jpg)
