Departments: Practice Points
Today, the focus with any wound care practice is documentation compliance. Not only are documenting details imperative for clinical outcomes and benchmarking your work, but also the chart that used to sit silently for years as the “alone” clinical record could possibly be viewed as a legal document for a malpractice claim, provide information to a payer to support the level of service billed to them, or provide the documentation needed to validate that you have met the standards of care for an accrediting body for the institution.
Enter the specialty wound care electronic medical record (EMR). This electronic means has revolutionized the way data are collected, collated, and delivered at the press of a button. Understanding how fields map to your documentation within the EMR is as important as understanding how reports, collated by your documentation, guide your practice and process. These reports can provide useful information to manage your clinical, operational, and financial processes that directly impact patient and facility trends, outcomes, and benchmarking.
Integrating evidence-based guidelines and templates, standardized dropdown lists, and lookup tables can ensure quality data captured and reported to support a meaningful platform.
Another key factor healthcare providers need to understand is how reports assist to fully leverage their EMRs. What reports drive your process improvement plans? Have you defined reports to manage your daily, weekly, monthly, and quarterly requirements? How do you measure your weekly healing rates? What are your outcomes, benchmarks, and trends? More importantly, how do you manage your outliers?
The following report sample discusses how one type of report can assist in managing your practice. The successive columns will review additional reports.
The Figure 1 depicts a sample Wound Healing Percentage Report. The report is interpreted as follows1:
©Net Health, 2013. Reprinted with permission.
Report description: The Wound Healing Percentage Report illustrates healing percentages—over a given time frame—providing a more accurate picture of wound healing success. This report compares the number of wounds healed to the total number of wounds closed and demonstrates how effectively the patient’s wounds are managed.
Report snapshot: In looking at this sample report, all wounds, within the specified date range, had a positive outcome related to clinical management practices with the exception of surgical wounds, which had an 83% wound healing outcome. At this point, it is prudent to conduct further research to determine why 17% of wounds did not experience a successful outcome.
Query the data by reflecting on your clinical practices: Was there a delay in seeking treatment, or were the patient’s comorbidities impeding the wound healing outcome, or were less than optimal wound management pathways implemented? Answering these questions assist in improving the department’s comprehensive outcomes.
Importance of data: This report can serve as a “report card,” allowing your physicians to compare their healing rates to the overall healing rates of the department. Also, reflecting on this report can assist in improving your Performance Improvement Plans.
Hess CT. Wound care quality in numbers: compiling discrete data drives meaningful reports. Todays Wound Clin 2013; 7: 14–16, 38.