In last month's column, "The Art of Auditing Documentation," we discussed many important reasons for auditing documentation, including assessing the completeness of a medical record, determining the accuracy of documentation, and discovering lost revenues. When auditing a medical record, the documentation is examined to determine if it adequately substantiates the services billed and identifies medical necessity for the services rendered. If this process is not conducted on an ongoing basis, incorrect or inappropriate documentation and coding practices, potential risks to the organization, compliance with the organization's policies and procedures, and compliance with payer regulations may not be identified.
Documentation components comprising the medical record provide the platform for medical necessity and continuity of care. Skin and wound care documentation can combine a variety of information-gathering tools reflecting the wound's status across the healing continuum. When assessing the patient with a skin or wound condition, the details of the documentation should reflect the following data points: chief complaint; history of present illness; medical, family, and social history; review of systems; physical assessment; risk assessment tools; manual assessment tools; skin and wound assessment tools; procedures; ordering supplies and tests; patient education details; plan of care; and discharge plan.
In this column, we will spotlight chief complaint, history of present illness, and medical, family, and social history. The remaining areas of documentation listed above will be discussed in future columns.
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 to the detailed history and physical captured by the practitioner, thus capturing the medical necessity for the visit. The clinician should document the specific reason the patient is visiting the practitioner. This statement should be clearly written, describing the reason for the patient's visit in his/her own words.
The history of present illness provides necessary subjective information for the practitioner to review in conjunction with the review of symptoms, physical examination, risk assessments, screening tools, and skin and wound assessments. The history of present illness should include a complete chronological account of the presenting problem to date. The majority of this information is subjective based on interviewing the patient. If there is more than 1 chronic condition discussed (such as lower leg pain, headaches), make sure to document this in the history of present illness. This will assist in justifying the needed orders.
There are many chronic illnesses or diseases, medications, allergies, diet, or activities of daily living that can lead to poor wound healing. A review of the patient's medical history, family events, and social activities should be captured. The clinician should pay particular attention to the following:
- Chronic illnesses, such as accidents or injuries that lead to chronic insufficiencies, autoimmune disease, blood disorders, bowel disorders, cancer, cardiovascular disease, cerebral vascular disease, diabetes, heart disease, hypertension, kidney disease, liver disorders, malignancies and associated treatments, musculoskeletal disorders, neurological infections, ostomy surgeries, revisions, diversions, peripheral vascular disease, prior hospitalizations, renal failure, and venous insufficiency.
- Medications, such as chemotherapeutic agents and steroids/corticosteroids
- Allergies, such as dressings and securement products, medications, and other.
- Vascular tests
- Radiological tests
- Dressing history, such as products used effectively in the past; and products that inhibited healing rate.
- Ostomy history, such as products used effectively in the past; and products that were ineffective from the past.
- Modality History, such as products used effectively in the past; and products that inhibited healing rate.
- Laboratory values, such as nutritional values (albumin, prealbumin, transferrin, total lymphocyte count); chemistry values (blood urea nitrogen, creatinine, liver enzymes, hepatitis panel, HbA1c, lipid panel); hematologic values (complete blood count, sedimentation rate, C-reactive protein, protein S, protein C); immunologic values (rheumatoid factor, immune complexes); and microbiology values (biopsy, quantitative cultures).
- Activities of daily living, such as alcohol use, illicit drug use, modality use, smoking, and eating patterns.
This thorough documentation will provide complete information needed for the clinician to link any and all disorders to the patient with the chronic wound.