Inadequate clinician documentation can lead to denials, audits, and loss of revenue to the agency. Let’s take a quick look at the eligibility list of patients first:
· Patients must be homebound
· Patients are under the care of a physician
· Patients will receive services under a plan of care established and periodically reviewed by a physician
· Patient is in need of skilled nursing care on an intermittent basis, physical therapy or speech-language pathology
· Has a continuing need for occupational therapy
With this being stated, just because a patient has a wound, does not qualify them for home care services on that basis alone. Often times, one hears, “Well, it is easier for the patient if we come to the home than sending them out”, or “The physician prescribed it, so therefore we need to do it”. Well, if the patient does not meet all of the coverage conditions above, they DO NOT qualify. Medicare home health services were never founded on the notion of making it “convenient” for the patient; rather, it is based on conditions of coverage. In many instances, patients who can go to outpatient wound clinics, or physician offices for treatment, are admitted into home care for the convenience. The information provided will detail documentation needed for patients who qualify for the Medicare benefit of home health.
Chapter 7 of the Medicare Benefit Policy Manual (40.1.2.8) states the following: “Care of wounds, (including, but not limited to, ulcers, burns, pressure sores, open surgical sites, fistulas, tube sites, and tumor evasion sites) when the skills of a licensed nurse are needed to provide safely and effectively the services necessary to treat the illness or injury, is considered to be a skilled nursing service”. Who better to start your episode off on the right foot than your admitting nurse! The admitting nurse is starting the race here and will hand off the baton to the next clinician, or keep it themselves. In either case, admitting documentation needs to be descriptive, concise, and with objective measurements.
SOC OASIS: Clear, descriptive, documentation on Integumentary Status
Location Surrounding skin
Type of wound Edema
Size (L × W × D ) Stoma
Tunneling/undermining Appearance of wound bed
Stage (if applicable) Drainage and amount
Odor Color and consistency
M1100/M2100: Is there a caregiver? Who will be learning the dressing changes? What is their availability? These OASIS items need to be consistent and detailed as to why or why not the patient or caregiver will or will not be providing services to the patient.
POC orders/485: For the purpose of this article, we will focus on wound care specific orders for the plan of treatment.
Specific goals/interventions for who will learn and perform care
If daily visits are required, there needs to be an end in sight. This frequency should be resolved quickly; usually no longer than a couple of weeks.
Specific wound care orders to include: site; frequency; clean with; rinse with; pack with; apply___; cover with___; secure with___.
Of course any comprehensive 485 will include appropriate diet, contributing factors, Braden Scale scores, and all other pertinent goals and interventions related to the unique condition of the patient and contributing disease processes.
Every Visit: Wound care documentation needs to be performed on every visit. Minimally, a wound care flow sheet is the BEST alternative to capturing all necessary information. There are many options out there, or you can create a standardized version for your agency. Each visit should include the following:
The location of the wound
The size of the wound (L: head to toe × W: hip to hip × D: deepest point of wound)*
If tunneling or undermining is present – document location and size (use clock system of location)*
The depth of the wound at the deepest point*
The nature of the drainage (odor, consistency, quantity and color)
If eschar or slough are present – document location and size
The surrounding skin (appearance, condition, status)
Description of wound bed (tissue, amount, tissue type)
Wound care provided, in detail, and by whom
Patient response to wound care – pain management/full assessment
S/S of infection; is the wound responding to current treatment?
* Wound measurements should be done weekly on the same day of the week if possible to prevent discrepancies whenever.
Additional Guidelines in Documentation:
Use objective measures like the size of the drainage on gauze e.g., 4cm of serous drainage noted to 4x4 covering versus mod drainage noted
Consistently document the etiology of the wound e.g., pressure ulcer, diabetic ulcer, arterial ulcer, stasis ulcer, surgical wound
Use percentages when documenting granulation, eschar, slough, and epithelialization- 10% green, tinged, stringy slough noted to left lateral side of wound at 9 o’clock
Remember to use descriptive words e.g., color, consistency
Always note presence or absence of s/s of infection and odor
Patient and caregiver compliance, understanding, return demo of wound care
Are there any changes noted in treatment regimen or medications?
Contributing factors to wound e.g., patient currently receiving chemotherapy, or patient with diagnosis of PVD
Remember to fully document any condition affecting the healing e.g., mobility, dietary status, continence, infection, non-compliance
So you thought wound care documentation was easy? Quite the contrary! Wound care documentation needs to be air tight; perfect at best to withstand a review, ADR, and prevent denials. If it’s NOT DOCUMENTED, it’s NOT DONE! Wound care for observation and ongoing assessment does NOT warrant the skill of a nurse. There must be a treatment regimen or condition change for the care to be skilled. When it comes to wound care denials, if you fail to demonstrate “skill” in your documentation, you may effectively “kill” your claim. Support it, justify it, understand it, and most of all, DOCUMENT IT!!!
The HHSM Nursing Newsletter is written by Kimberly A. McCormick, RN/BSN, Administrator of Phoenix Home Care, of Burr Ridge, IL. Her expertise is based on sixteen years of homecare experience.