wound care tools
Protect patients & your business with better documentation
by Michele Carr

Even though wound patients may have achieved celebrity status in home health under the Patient Driven Groupings Model (PDGM), there are some cautionary concerns agencies must consider before shifting their patient focus. Agencies cannot afford to overlook the fact that a wound patient is a high-risk patient—financially, medically, legally and administratively. This higher liability is due to several factors, including, but not limited to:

  • Wounds may worsen, leading to negative outcomes. Too often, wounds become infected, resulting in tissue damage, pain, osteomyelitis, gangrene, sepsis, amputation and even death.
  • In comparison to other patient groupings, wound patients frequently sue facilities, providers and their caregivers—including home health and hospice staff. In fact, lawsuits involving wound care issues are the second most common medical lawsuit, accounting for 25% of cases, according to an article published on the CME4Life blog.
  • The resources expended to treat a wound appropriately, both in terms of materials and utilization costs, can exceed the reimbursement for the payment period.
  • Wound charts are frequent targets of audits and state surveys.
  • Although concerning, each of the above risks can be mitigated with education and training. This article will focus on three subtle, yet common documentation mistakes I have seen often as a wound consultant, educator and auditor over the past two decades.

1. The treatment provided is inconsistent with wound care orders.

Wound treatment provided by a home health clinician must match the physician’s orders exactly. When evaluating a medical record, an auditor will compare each component of the physician’s wound care orders against the care provided by the home health clinician. Any deviation from the order (frequency, products used, treatments given, etc.) can be cited as noncompliance. This may seem obvious, but there are a couple of ways clinicians that may fail to realize they are out of compliance.

For example, when a physician requests a specific product by name and the home health agency (HHA) substitutes a comparable or equivalent product, this is an error. It is tempting to justify the substitution if the ordered wound care product is not on the formulary or the distributor cannot obtain it. Do not fall into that trap. An excuse for product substitution doesn’t matter; the HHA is out of compliance unless it either obtains the specific product requested by the physician or gets a physician’s order clarifying that an equivalent or alternative product may be substituted.

Another frequent error occurs when home health clinicians treat wounds before receiving the doctor’s orders. As clinicians, it is in our nature to want to provide the best care for our patients, and that usually means starting effective wound treatment as soon as possible. It is so tempting to jump the gun and apply advanced wound care products while waiting for orders. However, a clinician should only be providing first aid measures (gauze, tape, etc.) to wounds until physician orders are received—even if they have samples of the perfect wound care product in their trunk or bag.

Finally, be cautious about using name brands in wound documentation. Wound clinicians have become accustomed to using brand names to represent a category of products, such as stating that a “Wound VAC” is going to be placed rather than using the appropriate generalized term of “negative pressure wound therapy.” In this case, “Wound VAC” and “VAC” refers to a specific product from KCI/Acelity. If the KCI product is being used, there is no problem. But if that term is written and a different negative pressure device is used, then the case would be out of compliance. Try to avoid using brand names when referring to a general category of wound product.

2. Care coordination is absent.

Wounds are ever changing in size and appearance. When their characteristics change, especially if they worsen or new wounds occur, the treating physician should be informed promptly and a corresponding care coordination note should be placed in the chart that documents the interaction. That note should include what information was relayed, to whom it was given, when the discussion occurred and the provider’s response to the information. Without that information in the chart, a referring physician can easily blame a home health provider for a poor wound outcome by stating that they were never informed when new wounds presented or when the wound worsened. More importantly, good communication ensures that a patient’s wound care adapts as their wound changes, leading to improved outcomes.

3. Wound documentation is not consistent.

Defensible and accurate documentation is perhaps the most important thing a clinician can use to achieve a successful survey. A clinician’s documentation of their thorough assessment and treatment of a wound is their proof that the physician’s orders were followed, that treatment was provided and that the wound was evaluated. Encourage clinicians to take credit for their hard work by making sure that this information is detailed in the medical record.

Wound measurements are an essential part of the assessment and too frequently, they are omitted. Photographs can also be very helpful. Each HHA will have its own policy regarding the frequency of wound assessments. However, it is generally accepted in the industry that wounds should be evaluated at least weekly. Education should be offered to ensure that inconsistencies in wound assessments are minimized between clinicians.

Missing wound assessments may occur when a HHA is sharing a patient with a wound care center. The agency may mistakenly defer to the wound care center for the wound assessment and measurements and omit that information in their documentation. However, the HHA needs to include weekly assessments and measurements as well, especially when “skilled wound assessment” is being used
to qualify the patient for home health services. A completed and documented assessment is proof that the skilled wound assessment occurred.

In addition, skilled education and instruction given to the patient and caregiver is a key component of the medical record that may be missed. For example, a patient with a pressure ulcer might be educated on the need for frequent changes in positioning, pressure relief, support surfaces, moist wound healing, moisture management and good nutrition. Each time a principle is discussed, include it in the chart. If it is not in the chart, there is no way to prove that it ever happened. Skilled education can also be a justification for home health services.

Don’t forget to address the wound etiology in the chart. It is easy to miss the big picture as we hyperfocus on the wound. For example, since pressure injuries are caused by—you guessed it—pressure, document how the patient is positioned when the clinician enters the room, the patient’s mobility level, what pressure-relieving devices are present, if they are being used appropriately, if they are in good condition, etc. Including this type of information in the documentation indicates that a clinician is not just looking at the wound or replacing a wound dressing but is also addressing the root cause of the wound.

Following the above suggestions does not guarantee that you will survive a wound audit unscathed and uncited, but doing so will help you to avoid some of the sneaky documentation pitfalls. You may not have even thought of these mistakes, but you can bet that your surveyor has. Excellent wound care, documented accurately and thoroughly in the medical record, is best for the agency and best for the patient.

Michele Carr, RDN, DPM, NWCC, is an adjunct professor with Healiant Training Solutions and has dedicated her career to home health and hospice, with a focus in wound care, nutrition and OASIS coding. As both a registered dietitian and podiatrist, her expertise and experience give her a relevant and unique perspective in the ever-changing home health and hospice markets. Learn more at healiant.com.