The CORE of Your Wound Care Program’s Success: Documentation and ThinkFlow

Cathy Thomas Hess, BSN, RN, CWCN
Vice President and Chief Clinical Officer, Net Health

When I first started my journey in wound care back in the ’80s, documenting patient care was a straightforward task. You did your work, wrote it down for the paper record, and moved on to the next task.

But as healthcare has evolved, so has the complexity of our responsibilities, particularly when it comes to documentation. Today, it’s not just a routine task—it’s the strategic workflow of your practice. And it’s not about just about keeping records; it’s about delivering quality patient care, securing reimbursements, and avoiding potential penalties that can seriously impact your practice.

I think most of us understand, and can agree, on the basic tenets of wound documentation. Many wound care providers start to throw up their hands in frustration at how to achieve those goals as they continue to expand and evolve their practice while also meeting the demands of providing patient care and operating an effective business.

Documentation Confounds

Documentation takes time and is often confusing. For example, consider the requirements for describing wound edges. You must specify whether the edges are defined or undefined, attached or unattached, and note any specific conditions like epibole (rolled edges) or maceration (white, wrinkled skin due to excess moisture). The complexity arises because these terms can be subjective and require precise observation and terminology, which can vary among healthcare providers. This can lead to inconsistencies in documentation, potentially affecting patient, treatment and reimbursement outcomes.

Wound care providers also need to document several key elements to ensure compliance with regulations. This includes basic patient information such as name, date of birth, and medical history. They must provide a detailed wound assessment, describing the wound’s size, depth, location, and type. The treatment plan must be clearly outlined, specifying the treatments applied, including, but not limited to, dressings, medications, procedures performed, based on the presentation of the patient.

The progress note is the compilation of the work performed and serving as the source of truth for the patient encounter.  The medical record must include a plan of care containing treatment goals and physician follow-up. The record must document complicating factors for wound healing, as well as measures taken to control those factors when debridement is part of the plan.

Appropriate modification of treatment plans, when necessitated by failure of wounds to heal, must be demonstrated. . If allowed by the facility, photographic evidence of the wound can be included to track changes over time. Communication records with other healthcare providers, including calls to physicians and consultations, must be documented. It’s also important to note adherence to wound care protocols or provide explanations for any deviations.

Finally, accurate ICD-10 coding of the wound and related conditions is crucial for billing and reporting purposes.  There are numerous codes that cover a wide range of wound types and conditions. These include codes for open wounds, pressure injuries, non-pressure injuries, and complications related to wounds such as infections and disruptions.

Manually documenting all of this detail can add on average one to two hours to busy wound care providers’ workdays, but are important to the wellbeing of a provider or practice. Documentation details matter for the clinical, operational, regulatory, and economic (CORE) processes imparted in your business.

Why Is Documentation so Important in Wound Care?

For a task that takes so much time and can be complex, it helps to understand the “why” behind documentation.

• Ensures Continuity of Care: Your records allow other healthcare providers to seamlessly pick up where you left off, ensuring patients get consistent, effective treatment.
• Demonstrates Medical Necessity: Detailed documentation justifies the treatments you provide, which is crucial for getting reimbursed and protecting yourself against audits.
• Supports Regulatory Compliance: Adhering to documentation standards helps you comply with local and federal regulations, reducing the risk of penalties and fines.
• Enhances Clinical Outcomes: Accurate records help you make informed decisions, leading to better patient care and outcomes.
• Protects against Legal Risks: Thorough documentation provides a clear account of care provided, which can be your best defense if legal issues arise.

But let’s be honest—with everything else you have to manage, making sure your documentation is accurate can feel overwhelming. There just aren’t enough hours in the day.

Clinical, Operational, Regulatory, Economic

In talking with clients and colleagues over the past several years, the challenges of documentation increasingly became a hot topic.  That’s why I developed CORE—a method that stands for Clinical, Operational, Regulatory, and Economic. It’s not just a framework but a comprehensive approach to streamline and optimize the documentation process in wound care. Building on CORE, I created ThinkFlow, a strategy that merges workflow processes with CORE principles to improve efficiency and compliance in our practices. CORE focuses on four key areas:

1. Clinical. Ensuring that every patient care activity is thoroughly documented, reflecting the clinical reasoning and interventions applied.
2. Operational. Developing efficient workflows that integrate documentation seamlessly into your daily practice, cutting out redundancies and boosting productivity.
3. Regulatory. Keeping up with and adhering to all relevant regulations and guidelines to maintain compliance and avoid penalties.
4. Economic. Aligning your documentation practices with reimbursement requirements to secure appropriate payments and keep your practice financially healthy.

By addressing each of these areas, CORE helps you streamline your documentation processes, improving both your clinical outcomes and your bottom line.

ThinkFlow: Integrating Workflow with CORE

ThinkFlow takes CORE to the next level by integrating its principles into daily workflows. It’s all about understanding the “why” behind each step in the documentation process. Why are you documenting this? Why is it done this way? ThinkFlow helps you answer these questions and more, making your documentation process more thoughtful and effective.

Here’s how ThinkFlow works.

• Analyze Existing Workflows: Start by identifying your current processes and pinpointing areas of inefficiency or non-compliance.
• Map CORE Principles: Align each step of your workflow with the relevant CORE components to ensure comprehensive coverage.
• Implement Strategic Changes: Introduce modifications to streamline your processes, reduce redundancies, and enhance compliance.
• Continuous Evaluation and Improvement: Regularly review and update your workflows to keep up with regulatory changes and emerging best practices.

ThinkFlow turns documentation from a burden into a strategic asset that supports clinical excellence and operational efficiency.

The Real Cost of Improper Documentation

Now, let’s consider the cost of not getting your documentation right. Did you know that in the 2023 fiscal year, CMS estimated about $31.23 billion in improper Medicare Fee-For-Service payments? And guess what? More than 62% of that was due to improper documentation. That’s billions of dollars lost because of missing orders, insufficient support for services, incorrect coding, and missing attestations.

What does this mean for you? It means that poor documentation can lead to significant financial losses, increased audit risks, and even compromised patient care. But with CORE and ThinkFlow, you can help mitigate these risks by establishing clear, compliant, and efficient documentation processes.

A Practical Example: Documenting the Chief Complaint

Let’s bring this down to a practical level. How do CORE and ThinkFlow improve something as basic yet crucial as documenting a chief complaint?

Clinical Aspect: The chief complaint is the patient’s own words describing why they’re seeking care. This sets the stage for the entire clinical encounter.

Operational Aspect: Make sure the documentation of the chief complaint is seamlessly integrated into your patient intake process. Your staff should be trained to capture this information accurately at every visit.

Regulatory Aspect: CMS requires that for every service billed, the specific sign, symptom, or patient complaint must be documented to establish medical necessity. If this isn’t done right, your claims could be denied.

Economic Aspect: Accurate documentation of the chief complaint directly affects your reimbursement. It justifies the services you provide and ensures compliance with billing requirements, which safeguards your practice’s financial health.

Documentation Pointers:

• Always clearly and concisely state the reason for the patient’s visit at every encounter.
• Ensure that the documented chief complaint aligns with subsequent assessments and treatments.
• Regularly audit records to verify consistency and completeness in documenting chief complaints.

By applying CORE and ThinkFlow to this fundamental aspect of documentation, you enhance compliance, support appropriate reimbursement, and improve overall patient care quality.

Navigating Regulations

Navigating regulatory complexities can often feel like aiming at a moving target, but understanding these requirements is crucial for effective documentation. Each region has a specific Medicare Administrative Contractor (MAC).  Local Coverage Determinations are decisions made by MACs that apply to their specific jurisdiction. MACs create LCDs when there is no national coverage determination (NCD) or to further define an NCD for a specific area. And, in the absence of a specific LCD for a service, it is essential to ensure that all regulatory criteria are met.

To achieve this, familiarize yourself with your MAC and regularly review their guidelines and updates. Conduct ongoing education sessions to keep your team informed about regulatory changes, and implement routine documentation audits to ensure compliance. Additionally, create feedback mechanisms for staff to report challenges or uncertainties, enabling timely interventions and continuous improvement. By proactively managing regulatory compliance through CORE and ThinkFlow, you can reduce the risk of audits, denials, and penalties, ensuring smoother operational and financial performance.

Optimizing Workflow for Efficiency and Compliance

To achieve documentation excellence, your workflows must be both effective and efficient. They should help your clinicians capture the necessary information accurately without disrupting patient care. Ask yourself these key questions.

• What’s the WHY behind each step? Understanding the purpose and necessity of each documentation component is crucial.
• When do you update your workflows? Establish a regular schedule for reviewing and updating processes to adapt to changes in practice or regulations.
• Who is responsible for updates? Assign clear ownership to ensure accountability and timely revisions.
• How do EMR updates impact workflows? Stay informed about technological changes and integrate new features to enhance efficiency and compliance.

ThinkFlow Implementation Tips

• Process Mapping: Visually map out each step in your documentation process to identify inefficient processes and redundancies.
• Stakeholder Involvement: Involve your clinicians, administrative staff, and IT personnel in workflow development and revisions. Their input is invaluable.
• Technology Utilization: Leverage EMR capabilities and other digital tools to automate and streamline documentation tasks where appropriate.
• Continuous Improvement: Foster a culture that encourages feedback and regularly seeks opportunities to enhance processes.

When your workflows are optimized, you improve documentation quality, optimize your time with direct patient care, and enhance overall service delivery and satisfaction.

The Economic Impact: Documentation Details Determine Dollars

Thorough and compliant documentation has a direct impact on your practice’s financial health. It determines reimbursement levels, influences audit outcomes, and affects your ability to invest in resources and technologies that further improve patient care.

Effective documentation brings several economic benefits. Accurate and detailed records support claims, reducing the likelihood of denials and delays, which then optimizes reimbursement. Compliance with documentation standards minimizes the chances of costly audits and associated penalties, reducing audit risks. Comprehensive data enables better financial planning and resource allocation, leading to informed decision-making. Additionally, a demonstrated commitment to quality and compliance can enhance your reputation, attracting more patients and partnerships.

By embracing the CORE methodology and implementing ThinkFlow strategies, you position your practice not only for clinical excellence but also for robust financial performance and sustainability.

Embrace the Power of Process

Documentation requirements will continue to evolve. Amid these changes, effective documentation remains a constant cornerstone of successful practice. By understanding and implementing the CORE principles through the ThinkFlow strategy, you can transform documentation from a tedious obligation into a powerful tool that drives clinical excellence, operational efficiency, regulatory compliance, and economic benefit.

Remember, the power lies in the process. Take the time to analyze, understand, and optimize your documentation workflows. Equip your team with the knowledge and tools they need to succeed. Stay proactive in adapting to changes and challenges. In doing so, you not only enhance the care you provide but also ensure the long-term success and integrity of your practice.