OASIS Alert

Published on Fri Jan 28, 2011 PDF

Not all surgeries result in surgical wounds

OASIS item M1340 asks "Does this patient have a surgical wound?" This seemingly easy-to-answer question can actually be a stumbling block to OASIS accuracy.

The basics: You'll answer "0" if your patient has no surgical wounds. Report "1" if the patient has at least one observable surgical wound, and "2" if your patient has a known surgical wound that is not observable due to a non-removable dressing.

Tip: If your patient has both an observable and an unobservable surgical wound, report "1," says Judy Adams, RN, BSN, HCS-D, COS-C, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C.

You should only report "2" when the patient's surgical wound is not observable because it is covered by a dressing or device which the physician has ordered cannot be removed, Adams says.

Try this: "If the only surgical wound is not observable due to a non removable dressing, consider delayinganswering this item if the dressing will be removed and visualized by the same clinician within the 5 day assessment time period of SOC or 2 days of ROC," Fazzi Associates recommends in the OASIS - C Best Practice Manual. M0090 would then reflect the date the ulcer is visualized and the assessment is completed.

Knowing what is -- and what isn't -- considered a surgical wound can trip up the best of clinicians because OASIS logic doesn't always follow clinical logic. The following table based on Fazzi's best practice tips and Adams' input will help you to quickly classify some common types of wounds.

Bottom line: A surgical site closed primarily (with sutures, staples or a chemical bonding agent) is generally escribed in as a surgical wound until re-epithelialization has been present for approximately 30 days, according to CMS guidance for item M1340. This holds true unless the wound dehisces or presents signs of infection. After 30 days, the site is generally described as a scar and should not be included in this item. If you're not sure the wound fits the definition of a surgical incision, contact the physician for clarification.