OASIS Alert

Support your claims with better wound documentation.

Poor outcomes in wound healing can lead to adverse events and increases in unplanned hospitalizations as well as poor survey results. Good documentation could be your best defense.

Inconsistent wound documentation is as chronic as many skin ulcers, experts agree. Wound care is expensive in both clinician time and supplies. And a significant portion of claim denials result from inadequate wound care documentation, regional home health intermediaries report.

"Accurate and complete documentation is crucial for the medical review process, RHHI Cahaba GBA stresses in its Sept. 2005 Medicare Reference Guide for home health agencies.

Strategies: To prevent denials, clinicians should use a standardized tool for both the initial assessment and weekly follow-up on each wound, the RHHI recommends. And focus on providing good descriptive documentation. The OASIS assessment, plan of care and visit notes should be consistent, Cahaba instructs.

Protect yourself: Be sure you know the precise size, depth and width of wounds, as well as how often dressings are changed, how many dressings are on each wound and other extensive details on treatment and healing, says Glenda Motta, author of Defensive Wound Management and CEO of G.M. Associates in Mitchellville, MD.

Get Up To Speed On Documentation

Review these tips with clinicians to improve wound care documentation:a

• Keep a record. Your wound care record should include the wound type and location, shape and measurements, description of the wound bed and surrounding tissue, and any drainage noted, Cahaba says. Your notes should document the depth and circumference of the wound, any tunneling present, the type of tissue and the color and odor.

• Measure the wound regularly. This shows that the wound is healing. If the wound is not showing progress, the documentation needs to reflect clearly what you plan to do differently to try to enhance or stimulate healing.

• Go beyond the measurements. Note the amount of necrotic tissue present on the wound both before and after the wound care. Note the wound's appearance each time you treat the patient, including the amount of granulation tissue and the appearance of the periwound area.

• Use your camera. Take pictures of the wound when you begin therapy and at least every two weeks. "Photographs are helpful in supporting the severity of the wound and wound type," Cahaba says. Also take photos of wounds before a patient is transferred to a different care provider, whenever there is a change in the wound condition and every two weeks even if there is no change, advises Burtonsville, MD health care attorney Elizabeth Hogue.

But be sure your pictures help you rather than hurt you. "If you're going to chronicle wound healing with pictures, take good color pictures that actually show the wound's progress," warns medical director Mark Heard, who spoke on the topic at a regional meeting of the American Medical Directors Association.

• Document any interdisciplinary education or care you are engaging in. If you are working with a dietitian to improve a patient's nutrition, a physician to ensure certain aspects of her blood chemistry are in good ranges, or a diabetes care manager to help the patient manage her blood sugars better, you should include these details in the record.

• Support trauma wound coding. If a wound is designated in your diagnosis coding as a trauma wound, be sure to document the type of injury that caused the wound and the location of the wound, Cahaba warns.

• Document why the service you are providing is skilled. Skilled nursing can be required to observe and assess the wound and to teach the family to care for the wound, the Centers for Medicare & Medicaid Services instructs in CMS Medicare Benefit Policy. Be sure to document the medical necessity for observation and assessment in the record to avoid downcoding.