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Grow Your Rehab Therapy Practice Using Paid Ads and Search Engine Marketing

When done right, paid advertising and search engine marketing are amazing tools to reach new patients and grow your business. By applying several basic tactics, you can start using powerful digital advertising platforms like Google and Facebook to target specific audiences and help ensure a steady flow of business for your practice. Click to View […]

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Five Key Stressors Hospice Professionals Face, with Guidance for Support

Hospice professionals help others face death and loss, while juggling interdisciplinary communications, quality compliance regulations and ever-evolving technologies. You are continually there for families and their dear ones who are passing away. But what about you? Get the eBook In caregiving professions, it is easy to get swept up in the needs of others and forget […]

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Net Health’s CIO discusses diversity and how it can build a stronger organization

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Industry News Wound Care Medical Record Documentation

Wound Care Medical Record Documentation

October 1, 2018 by Cathy Hess , BSN, RN, CWCN, VP, Chief Clinical Officer for Wound Care

The goal of 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.

Chief Complaint

The chief complaint is the first step toward complete 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.

To read the full article in “Advances in Skin & Wound Care” by Cathy Thomas Hess, click here.

Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.

Download a brochure and learn how Net Health 360 professional services programs conquer the most complex problems in specialized lines of work.


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.

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Filed Under: Industry News, Wound Care

About the Author

Cathy Hess , BSN, RN, CWCN

VP, Chief Clinical Officer for Wound Care

Cathy oversees clinical and professional services for Net Health. Cathy gained over 25 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. She is the author of The Clinical Wound Manager™ Manual Series, Clinical Guide to Skin and Wound Care – Seventh Edition (also translated into Italian and Portuguese).


See all posts by Cathy Hess , BSN, RN, CWCN

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