Wound Care Provider Documentation

Updated: Mar 7, 2019

By: KATHLEEN WATSON RN | Lead Quality Coordinator | kwatson@ameriwound.com

Documentation demons from an auditing perspective....

EMR for wound care is to stay. So it is extremely important that Providers embrace its importance and prioritize their time to accommodate avoiding its pitfalls. Acceptance comes first. If a provider does not buy in to using an EMR it is a slow climb up a long mountain on a hot day. It is a difficult climb without acceptance because EMR’s can be uniquely quirky. Embracing their quirks will ensure it is a tool and not a torment. I will identify some pitfalls I have seen and hopefully provide tips for avoidance of these pitfalls. Or at least a way out if they are inadvertently stumbled on.

As an auditor for a AmeriWound I see the following barriers to providers using the EMR as a tool.

Time constraints

Often the provider feels rushed to keep up the pace of rounds and does not do documentation until the end of rounds. I recommend that notes be written immediately after each patient is seen. Or at least that the wounds are methodically written out on paper and viewed by another set of eyes. Preferably the wound care nurse. This will ensure that the correct information is transcribed at the end of rounds. Common mistakes I see because of rushing is wound location errors. Left Vs Right.

Back staging a wound

Another common mistake in documentation is back staging a wound simply because the wrong box was checked. Back staging of a wound can cause tremendous problems for the facility if they are surveyed. It may look as though they falsified records in order to avoid change of condition paper work and citations.

Some EMR’s have the ability to be followed up. That benefit comes with some risks. Another common thing I see with that feature is that perhaps during that copy forward function things are not removed from notes that no longer apply. This may also be because of rushing. This can cause treatment errors and may have the potential to have negative impact on the patients. It can also cause duplicate debridement information that unless found and eliminated can be a problem when the charts are audited.

To be sure there is a learning curve with every EMR. I would recommend that a provider relax in to the process, ask questions, and be willing to take constructive correction in an effort to get better at using them. Most employers have resources for the learning curve. Resources such as being able to mirror the provider’s computer and walk them through the steps while out in the field if they get hung up while doing rounds.

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