In last month’s column, “Mapping Documentation to Support Your Work Performed,” we discussed the importance of understanding the documentation components comprising the medical record. These documentation points provide the platform for medical necessity and continuity of care.
In this column, we will spotlight review of systems, physical assessment, risk assessment tools, manual screening techniques, and wound/skin assessment. Other areas of documentation will be discussed in future columns.
The review of systems is defined by Current Procedural Terminology, CPT* 2011, as “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.” Generally the review of symptoms is a question-and-answer discussion related to the patient’s complaints or problems identified during the visit. The review of symptoms provides necessary subjective information for the practitioner to review in conjunction with the history of present illness; medical, social, and family history; physical assessment; and wound/skin/ostomy assessment.
The physical examination is generally a focused examination, pertinent to the skin condition, ostomy, or wound healing history. Generally, the physical examination is based on the patient’s history and the nature of the presenting problems. Documentation of the affected system(s) is mandatory in this section. The physical examination provides necessary objective information for the practitioner to review in conjunction with the history of present illness; medical, social, and family history; review of systems; and wound/ostomy/skin assessment.
Risk assessments are screening tools used as predictors to ensure systematic evaluation of individual risk factors. Risk assessment tools exist for areas of the skin at risk, such as pressure ulcers and diabetic foot ulcers. Nutritional risk assessment tools assist the practitioner in understanding the strategies necessary to identify the levels of nutritional risk. Manual risk assessment tools are part of the prevention of many disease states. Other factors (such as laboratory values, radiologic studies, and vascular studies) should be taken into consideration when evaluating a patient at risk. The risk assessment provides necessary objective information for the practitioner to review in conjunction with the history of present illness; medical, social, and family history; review of systems; physical examination; and wound/ostomy/skin assessment.
Manual screening tools are objective findings that assist the clinician in determining an accurate diagnosis. Manual screening tools include the ankle brachial index, culture tests, lower-leg and foot assessments, palpation of pulses/Doppler (ultrasound), segmental blood pressures, Semmes-Weinstein monofilament test, transcutaneous oxygen tension, vibration perception threshold assessment, and so on. The results from the manual screening technique process provides necessary objective information for the practitioner to review in conjunction with the history of present illness; medical, social, and family history; review of systems; physical examination; and wound/ostomy/skin assessment.
Wound care documentation can combine a variety of information reflecting the wound’s status across the healing continuum. Providing an accurate description of the wound’s characteristics is critical during each patient visit. These objective findings assist the clinician in mapping the care during the wound management process. The values obtained include etiology, qualitative information, and quantitative information.
Establishing the etiology or cause of the wound or skin condition will help identify the correct classification and management process. Underlying medical conditions such as poor nutrition, diabetes, or neuropathy may explain why the wound is healing slowly. These underlying conditions need to be treated concurrently. Finally, treatment history is significant because the clinician may learn which management modalities have been successful or not.
Qualitative information should capture the anatomical location, classification of tissue layer destruction, edema or swelling of tissues, wound exudate, odor, pain, periwound skin description, type of tissue exposed, wound bed description and wound color, and wound margin condition. Quantitative information may include ankle and calf circumference, photograph of the wound, surface area of wound, wound depth, and undermining.
Remember, the goal of your documentation details is to provide the highest possible degree of clinical specificity to ensure accurate interventions and diagnosis. Diligent documentation is the key!
*CPT is a registered trademark of the American Medical Association, Chicago, Illinois.