Today, the focus with any wound care practice is documentation compliance. Not only are documenting details imperative for clinical outcomes and benchmarking your work, but also the chart that used to sit silently for years as the “alone” clinical record could possibly be viewed as a legal document for a malpractice claim, provide information to a payer to support the level of service billed to them, or provide the documentation needed to validate that you have met the standards of care for an accrediting body for the institution.
Enter the specialty wound care electronic medical record (EMR). This electronic means has revolutionized the way data are collected, collated, and delivered at the press of a button. Understanding how fields map to your documentation within the EMR is as important as understanding how reports, collated by your documentation, guide your practice and process. These reports can provide useful information to manage your clinical, operational, and financial processes that directly impact patient and facility trends, outcomes, and benchmarking.
Integrating evidence-based guidelines and templates, standardized dropdown lists, and lookup tables can ensure quality data captured and reported to support a meaningful platform.
Another key factor healthcare providers need to understand is how reports assist to fully leverage their EMRs. What reports drive your process improvement plans? Have you defined reports to manage your daily, weekly, monthly, and quarterly requirements? How do you measure your weekly healing rates? What are your outcomes, benchmarks, and trends? More importantly, how do you manage your outliers?
The following report sample discusses how one type of report can assist in managing your practice. The successive columns will review additional reports.
Read the rest of the article at Advances in Skin & Wound Care.
An excerpt from an article originally published in Advances in Skin & Wound Care, written by Cathy Thomas Hess, BSN, RN, CWOCN, VP and Chief Clinical Officer at Net Health