The burden of chronic wounds is high. Associated morbidity, decreased quality of life, and, in some cases, mortality are among the many reasons significant interest is focused on the prevention and treatment of wounds and the patients you serve each and every day. It has been estimated that a single diabetic ulcer carries a cost of nearly US $50,000, and chronic wounds as a whole cost the medical system over US $25 billion per year.1 Worryingly, the number of patients affected is growing because of the increasing prevalence of diabetes and other chronic diseases that can affect wound healing.
Regardless of the monetary value of a single ulcer, the cost to the medical system as a whole, or how many patients are affected annually, the most clinically relevant question is: "How are you managing and documenting the outcomes of these patients in your health system?" To ensure accurate documentation and payment for wound care, you must invest time to understand the rules and regulations governing the management of your patients and create best practices for your processes and associated clinical and operational workflows.
The purpose of a workflow is to perform a sequence of tasks as quickly and as smoothly as possible. To me, effective workflows are those that increase your capacity for work and productivity. But how often do we review our workflows to ensure they are clinically effective, operationally appropriate, and not "broken," all of which could lead to missing documentation elements or denials? The root cause of broken workflows lies in your process-you must periodically assess them to certify that the information they contain is accurate and up to date.
Knowing that a workflow is a chain of tasks that happen in a sequence, as well as a process you work through on a regular basis, you need to ask yourself a few questions when managing them. These include the following:
1. How often do you review your workflow?
2. How, exactly, do you complete each step?
3. What tools and strategies do you need to complete the step?
4. Who is in charge of which steps?
5. What team member is responsible for documenting information collected during the patient's encounter?
6. How do you know if your workflows are effective?
7. Do you audit your staff's actions based on the workflows employed?
Further, understanding what documentation is necessary to develop and sequence the proper workflows is imperative. This understanding will align the appropriate people to drive the information for a complete medical record. Common elements for documentation include the following:2
Chief Complaint
The chief complaint is the first step toward complete documentation for the skin and wound care patient. The chief complaint bridges the reason for the patient's visit and the detailed history and physical examination captured by the provider, distilling the medical necessity for the visit. This statement should be clearly written, describing the reason for the visit in the patient's own words.
History of Present Illness (HPI)
An HPI provides necessary subjective information for the provider to review in conjunction with a review of symptoms, physical examination findings, risk assessment and screening tools, and skin and wound assessments. The HPI should include a complete chronological account of the presenting problem to date, and much of the information will be based on an interview with the patient. If there is more than one chronic condition discussed (ie, lower leg pain, headaches), make sure to document this in the HPI. This will assist in justifying the needed orders.
Past Medical, Family, and Social History
There are many chronic illnesses or diseases, medications, allergies, diets, or activities of daily living that can lead to poor wound healing. A review of the patient's medical, family, and social history should be captured. This thorough documentation will provide complete information needed for the clinician to link any and all disorders to the patient with the chronic wound.
Review of Systems
Defined by the CMS as "an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced," a symptom review is a general discussion related to the patient's complaints or problems identified during the visit that provides necessary subjective information for the provider to review in conjunction with the other documentation items listed here.
Physical Examination
A focused examination pertinent to the skin condition, ostomy, or wound healing history, the physical examination is based on the patient's history and the nature of the presenting problems and provides necessary objective information for the provider to review in conjunction with the other items listed here. Documentation of the affected system(s) is mandatory in this section.
Risk Assessment
Risk assessments are used as predictors to ensure systematic evaluation of individual risk factors for conditions such as pressure ulcers and diabetic foot ulcers. Other factors (ie, laboratory values, radiologic studies, vascular studies) should be taken into consideration when evaluating a patient at risk. Providers should review these objective findings in conjunction with the other items listed here.
Manual Screening Tools
These tools provide objective findings that assist the clinician in determining an accurate diagnosis. The results comprise further objective information for the provider to review in conjunction with the other documentation areas discussed.
Wound/Skin Assessment
Wound care documentation can combine a variety of information reflecting the wound's status across the healing continuum. Providing an accurate description of the wound's characteristics is critical during each patient visit. These objective findings assist the clinician in mapping care management. The values obtained include etiology, qualitative information, and quantitative information. Establishing the etiology or cause of the wound or skin condition will help identify the correct classification and management process. Underlying medical conditions such as poor nutrition, diabetes, and/or neuropathy may explain why the wound is healing slowly and need to be treated. Finally, treatment history is significant because the clinician may learn which management modalities have been tried and were successful or unsuccessful. Qualitative information should capture the anatomical location; classification of tissue-layer destruction; edema; or swelling of tissues, wound exudate, odor, pain, periwound skin description, type of tissue exposed, wound bed description and wound color, and wound margin condition. Quantitative information may include ankle and calf circumference, photographs, the surface area of wound, wound depth, and undermining.
Procedures Performed
Components of the documentation around procedures performed include, but are not limited to, consent for the procedure, the name of the physician and/or clinician performing the procedure, preoperative diagnosis, procedure description, anesthesia used, complications, postoperative diagnosis, and the procedure performed (eg, techniques and tissues removed). Review your National and Local Coverage Determinations or Articles related to the specific procedure performed; you must document certain important details within your procedure note to make you fully compliant.
Ordering Supplies and Tests
The provider must supply an order for all of the care the patient receives related to the treatment. In many cases, it is important that the provider document the reason for the order to justify the actions taken.
Patient Education
This is a cornerstone of successful wound and skin care. The educational needs of the patient should be evaluated on an individual basis beginning with the nonjudgmental assessment of the patient's current knowledge base relevant to the plan of care determined. An educated clinician should direct the educational activities. Validating the impact of the education by measuring retention of the material is paramount for a successful plan.
Plan of Care/Discharge Instructions
Designing, developing, and executing a clinical plan of care that is straightforward and comprehensive is paramount. Discharge summaries should be provided to patients in writing. The summaries can include the diagnosis, summary of tests or procedures performed, medications prescribed during the visit, potential adverse effects of any tests or medications, and follow-up instructions. Specific requirements can be found within the clinical and operational standards of your institution and the governing bodies that oversee your work.
There are many steps that must occur to build proper workflows. When assessing the patient with a skin or wound condition, the details of the documentation should reflect the data in the complete medical record.
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