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Electronic Health Record Wound Care Checklists

Hess, Cathy Thomas BSN, RN, CWOCN

Advances in Skin & Wound Care: June 2012 - Volume 25 - Issue 6 - p 288
doi: 10.1097/01.ASW.0000415351.60425.6e
Departments: Practice Points

Cathy Thomas Hess, BSN, RN, CWOCN, is President and Director of Clinical Operations, Well Care Strategies, Inc (WCS). WCS specializes in focused software solutions, Your TPS® EMR, and mapping best clinical, operational, and technology practices.

Please address correspondence to: Cathy Thomas Hess, BSN, RN, CWOCN, 4080 Deer Run Court, Suite 1114, Harrisburg, PA 17112; e-mail:

As detailed in the Health Information Technology for Economic and Clinical Health Act, the government’s research concluded that using an electronic health record (EHR) would serve to improve patient care, increase patient safety, and simplify compliance in the US healthcare system, as well as reduce costs in the long term, minimize errors, and increase productivity and administrative efficiency. As the government continues to roll out its plan, hospitals will need to have their EHR in place, be able to send “meaningful” data to CMS, and measure the actual impact on patient care.

Providers should establish an electronic assessment, documentation, and clinical and financial outcome system to capture all work and outcomes in a database. These outcome data can then be used to improve critical pathways, product formularies, contract fees with payers, and patient satisfaction.

Keeping your finger on the pulse of clinical and regulatory changes for documentation requirements can be a daunting task. Designing a checklist to maintain compliance may be one way to structure the oversight needed to meet expectations.

* Develop a clinically and operationally sound wound care department incorporating inpatient and outpatient work.

* Develop specific policies and procedures for skin and wound management services.

* Develop evidence-based prevention and intervention skin and wound care pathways.

* Use technology to reduce length of stay, number of dressing changes, number of professional visits, time to heal, and total cost of care.

* Design a skin and wound care formulary based on clinically proven efficacy and cost-effectiveness, availability, ease of use, function, and direct cost.

* Identify all International Classification of Diseases, Ninth Revision/10th Revision, CPT, HCPCS, Pass-Through, New-Technology, and local codes that represent the diagnosis, evaluation and management service, procedures, and products that need to be included on payer claim forms.

* Integrate a photodocumentation process with your electronic medical record.

* Utilize outcomes to improve efficiency in your department.

* Educate and validate competency of all levels of staff, including physicians, in how to assess, aggressively manage, and appropriately document skin and wound care.

* Design a supply management system that controls product utilization to control costs and waste.

* Obtain cost reductions based on volume purchases, due to standardization of products.

* Implement a delivery system that prevents delays in management and oversupplying products.

* Develop a multidisciplinary plan of care with clearly defined end points.

* Implement early, aggressive, state-of-the-art skin and wound management.

* Assess wounds accurately, and document them completely.

* Accurately select the appropriate diagnoses and map to medical necessity.

* Order wound management modalities based on assessment, an outcome-oriented care plan, the skill of patient and caregiver, and payer guidelines.

* Be sure physician orders include all required components and document medical necessity for modalities ordered.

* Incorporate macros or templates through a keystroke allowing the clinician/physician to quickly document text supporting regulatory and accreditation standards, avoiding the cost of transcription and/or the time of repetitive documentation.

* Provide patient and caregiver education regarding efficient use of appropriate dressings, drugs, and medical equipment.

* Reach achievable clinical and financial outcomes and patient satisfaction in the least amount of time, using the least amount of labor and material resources.

* Establish a method of transferring documentation about origin of wound, surgery date (if applicable), type of debridement (if applicable), original stage of wound, wound assessment, diagnoses, and physician orders.

* Initiate timely referral to the next logical level of care.

* Obtain new referrals for well-managed wound care, which generates more revenue.

* Drive root-cause analysis reporting and track performance metrics for optimal clinical business intelligence through select features.

* Support quality indicators.

* Drive regulatory compliance.

* Implement a care coordination process.

© 2012 Lippincott Williams & Wilkins, Inc.