Abstract
PURPOSE: The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention.
METHODS: From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding.
RESULTS: The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group ([chi]2 = 15.99, P < .001), complete documentation of coding for diagnoses and procedures ([chi]2 = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures ([chi]2 = 14.96, P < .001).
CONCLUSIONS: An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.