Comprehensive documentation is critical for reimbursement of services and products. It also justifies their medical necessity, and it reflects the care required to prevent or treat wounds. Regulatory agencies, independent of health care setting, set the requisite documentation for reimbursement, and their requirements should always be reviewed before applying for coverage.
In general, essential wound care documentation includes the following:
- regular assessment and reassessment of the wound (daily or weekly, for example)
- characteristics of the wound, including length, width, depth, exudate amount, tissue type, and pain
- repositioning and turning schedules
- use of pressure-reducing support surfaces (both bed and chair)
- local wound care
- routine skin assessment and care
- moisture management
- nutritional status
- any change in clinical status or wound healing progress
- patient or caregiver education
- Minimum Data Set (MDS 2.0) per schedule in a skilled nursing facility
- Outcome and Assessment Information Set (OASIS) per schedule in home health care.
Sources: Lyder CH. Regulation and wound care. In: Baranoski S, and Ayello EA. Wound Care Essentials: Practice Principles. Springhouse, PA: Lippincott Williams & Wilkins; 2004. p 35–46.