Cath Lab Digest

Documentation in wound care is critical for reimbursement. To ensure payment, a comprehensive individualized plan, indicating the wound problem and goal of treatment must be in the medical record. The American Physical Therapy Association’s (APTA) “Guide to Physical Therapist Practice” recommends the five-stage management system; examination, evaluation, diagnosis, prognosis, and intervention.

Wound care is usually best performed by a team of experts. Your team may consist of any combination of diabetic educators, dieticians, nurses, nurse practitioners, occupational therapists, orthotists, pedorthists, physical therapists, physicians, physician assistants, and podiatrists. The physician or advanced practice nurse will function as the coordinator of care, utilizing the expertise of other team members to accomplish the wound care goals. The team members conduct evaluations within their specific scope of clinical practice.
The examination phase of a wound consultation is assumed to be the most important aspect, particularly identifying any pre-existing signs or symptoms, relevant systems review and tests and measures. It is very important to identify all risk factors.

Crucial to the evaluation of the wound is identifying the cause of the wound to establish a diagnosis and prognosis. This allows the clinician to identify the class and severity of the wound by stage, thickness, or colors. In broad terms, wounds are lesions caused by trauma or surgical interventions, and all other lesions would fall into some sort of ulcer classification. However, the ICD-9 diagnosis coding system is a poor one when it comes to proper coding of ulcerations. Using ICD-9, it is not possible to properly designate mixed arterial/venous or inflammatory ulcerations, for example. In addition, a lesion, which began traumatically but persists in a non-healing state for many months, could be classified as a chronic ulcer. Medicare provides no guidance as to how to deal with these issues. For the rest of this article, the term wound to refer generically to all skin lesions, whether they would be classified as a wound or an ulcer in the ICD-9 coding system. Ironically, using the term wound and ulcer interchangeably in clinic notes can be cause of confusion and even lead to coding errors and should be avoided in clinic documentation.

In addition to determining a diagnosis, usually done by an advanced practitioner, documentation is needed as to the details of the wound appearance. The visit-by-visit wound evaluation is typically carried out by the clinic therapy or nursing staff. This provides the comparative data that, over time, details the progression (or lack thereof) of the wound. It is this ongoing evaluation and the documentation of such that provides the necessary data to support the advanced and ancillary treatment modalities which may be required. Thus, this documentation is vitally important to the patient and the clinic. Phrases such as, in my medical opinion are meaningless without objective data to substantiate medical necessity.

Wounds are dynamic and change over time. The evaluation of the status of the wound at each encounter enables us to set goals for management. If the goals are based on an accurate and complete evaluation of the wound, and the treatment is chosen based on that evaluation, then the clinical decisions should be appropriate for that patient.

Regardless of whether one uses paper or electronic data collection tools, information should be gathered in a systematic way to allow comparison from visit to visit. The following documentation points may provide guidance.

Components of the Wound Evaluation
Wound Etiology. Should be documented with each encounter.
Location. Documentation of the location can also support the etiology. For example, an ulcer documented over a bony prominence is indicative of a pressure ulcer, one at the medial ankle suggests venous, and plantar foot, of course a diabetic foot ulcer. In most settings, wounds are generally assigned a number. Consequently, when more than one wound is located in a general area, using descriptors such as anterior, posterior, medial and lateral, and so on can help to differentiate the individual wounds. Consistent terminology should be applied. Avoid using non-medical terms for location such as above, or below.

Wound Size. Wound measurements are typically done on a weekly basis. In a recent National Pressure Ulcer Advisory Panel (NPUAP) newsletter (Fall, 2007) the recommendation was made to measure wounds using the clock method, with the 12 o’clock to 6 o’clock (or head to toe) measurement being the length, and the perpendicular to that, or 3 o’clock to 9 o’clock being measured as the width. This method is counter-intuitive to some, because for some wounds the length may be smaller than the width. The alternative is to use the longest measurement as the length, with the area perpendicular to that measured as the width. The practical reality is that one chooses a method, makes that the protocol followed, and all staff consistently measure in the same manner. By convention, wounds are normally measured in centimeters. Some clinics measure in millimeters. There is no data to support that measuring in millimeters is more accurate since most rulers are centimeter based. The clinic should decide on a method and follow it.

Wound depth is measured as an absolute number accounting for the space measured from the base of the wound to the skin or epithelial edge. As an additional measurement, any undermining or sinus tracts present should be documented. The location of undermining can also be designated using the clock face technique (eg, 2 cm of undermining at 2 o’clock).