The Art of Effective Medical Record Documentation in Wound Care

The goal of wound care documentation is to provide the highest possible degree of clinical specificity to ensure accurate interventions and diagnosis as well as to adequately demonstrate medical necessity for the services rendered and substantiate the billed services.

Let’s review components of skin and wound documentation that may comprise your medical record.

Wound Documentation: Key Components

Chief Complaint

The chief complaint is the first step toward complete wound documentation for the skin and wound care patient. The chief complaint bridges the reason for the patient’s visit and the detailed history and physical data captured by the practitioner about the medical necessity for the visit.

The clinician should document the specific reason the patient is visiting. This statement should be clearly written, describing the reason in the patient’s own words.

History of Present Illness

The history of present illness (HPI) is a key element of medical necessity and provides subjective information for the practitioner to review in conjunction with the review of symptoms; physical examination; risk assessments and screening tools; and skin and wound assessments.

The HPI should include a complete chronological account of the presenting problem to date. Most of this information is subjective and interview-based. If there is more than one chronic condition discussed, make sure to document each finding in the HPI. This will assist in justifying the needed orders.

Past Medical, Family, and Social History

There are many factors that can lead to poor wound healing. A review of the patient’s past medical history, family events, and social activities should be captured.

The clinician should pay attention to:

• Chronic illnesses that lead to chronic insufficiencies, autoimmune diseases, blood disorders, bowel disorders, cancer, cardiovascular disease, cerebral vascular disease, diabetes, heart disease, hypertension, and so on.
• Medications such as chemotherapeutic agents, steroids/corticosteroids, and so on.
• Allergies to dressings and securement products, medications, and others.
• Vascular tests
• Radiologic tests
• Dressing, ostomy, and modality history, to review products that were previously effective or inhibited healing.
• Laboratory values to review nutrition, chemistry, hematologic, immunologic, and microbiology values, and so on.
• Activities of daily living including alcohol use, illicit drug use, modality use, smoking, eating patterns, and other.

This thorough documentation will provide complete information needed for the clinician to link all disorders to the patient with the chronic wound.

Review of Systems

The review of systems is defined by Current Procedural Terminology (CPT)^* as “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.” Generally, it is a question-and-answer discussion related to the patient’s complaints or problems identified during the visit.

The review of symptoms provides necessary subjective information for the practitioner to review in conjunction with the HPI; past medical, social, and family history; physical assessment; and wound/skin/ostomy assessment.

Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.