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Advances in Skin & Wound Care:
doi: 10.1097/01.ASW.0000422623.40278.06
Departments: Practice Points

The Power of an Electronic Medical Record: Documentation Drives Data

Hess, Cathy Thomas BSN, RN, CWOCN

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Author Information

Cathy Thomas Hess, BSN, RN, CWOCN, is Vice President and Chief Clinical Officer, Net Health Systems, Inc. Please address correspondence to: Cathy Thomas Hess, BSN, RN, CWOCN, via e-mail: cthess@nhsinc.com.

As I have written in many columns, proper documentation provides guidance for appropriate management decisions, evaluation of the healing process, support for reimbursement claims, and defense for litigation. The data obtained from the documentation proves your worth.

As you move forward with your electronic medical record (EMR) checklist, ensure your documentation meets your clinical and operational needs. Define your checklist for documentation success by considering the following:

* scheduling module

* patient and physician portals

* secure e-mail exchanges

* smart EMR to meet the needs of all practicing clinicians and physicians in your department as well as the patient who may access their defined information

* clinical decision and practice management tools to alert the user to medication errors and adverse drug interactions, track test results and patient follow-up

* interfaces to pull data in and out of your system, and clinical and operational compliance and audit mechanisms to ensure success

* compliance with Meaningful Use and Accreditation and Certification Standards

* audit trail to identify work performed through documentation

* reporting for outcomes and benchmarking.

Over time, the providers with the clinically best and most cost-effective skin and wound care outcomes, the best quality assurance results, and the highest level of patient satisfaction will have the most referrals and the most profitable business. The following is a checklist of steps necessary for all providers to achieve both clinical and financial goals:

√ Develop a clinically and operationally sound wound care department focusing on inpatient and outpatient work.

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

√ Develop evidence-based prevention and intervention 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 ICD-9/10-CM, 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 Quality Measures.

√ Integrate a photodocumentation process with your EMR.

√ 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 internally or externally, 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 endpoints.

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

√ Assess wounds accurately, and document them completely.

√ Accurately select the primary diagnosis, 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 that allow 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.

√ Prepare a discharge summary that includes information required by the next provider to manage care and supplies in a cost-efficient manner.

© 2012 Lippincott Williams & Wilkins, Inc.

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