OASIS Alert

Published on Sun Jun 26, 2011 PDF

Tip: E-photos can help speed wound care advice.

Poor outcomes in wound healing can lead to potentially avoidable events and increases in unplanned hospitalizations. Good documentation could be your best defense.

Inconsistent wound documentation trips up many OASIS assessments and the resulting claims. Make sure your wound care documentation backs up your OASIS coding and claims, or you'll pay the price.

Keep Your Camera Handy

Documenting wounds with photographs provides a couple of special perks, says Judy Adams, RN, BSN, HCS-D, COS-C, with Adams Home Care Consulting in Chapel Hill, N.C.

Benefit: First, having an actual picture of the wounds you document in the Integumentary Status OASIS items is so much more convincing than just a description. Should medical reviewers pull the claim, this photo could go far in making your case with your intermediary.

Benefit: Secondly, having a camera that can download pictures to the electronic record or attach photos to an email can actually help improve the wound care you provide, Adams says. Being able to share photographs of wounds electronically with the physician or a consulting wound nurse specialist allows her to see the progress the wound is making so that she can make additional recommendations on future treatments.

Best bet: Establishing one clinician to manage the care of a wound care patient helps keep descriptions consistent, Adams says.

Whether your agency uses a camera or narrative documentation, you'll need to set up standard policies regarding how often wounds are described or photographed and measured, Adams advises.

For wounds seen frequently, it's best to document measurements and descriptions at least weekly, Adams says. Establishing a set day of the week for this activity is a good way to keep documentation consistent.

The method for measuring the wound needs to be consistent as well, Adams says. There are many tools for assisting with accurate wound measurement that are inexpensive and provide an excellent adjunct to the wound description.

Tip: See the sidebar on page 65 for new wound photodocumentation policy tips from The Wound,Ostomy and Continence Nurses Society.

When you're caring for a patient with multiple wounds, make certain to carefully document each wound location and type, Adams says. This way, all the clinicians who see the patient can reference the wounds the same way. "There is little that is more frustrating than to read a chart and find considerable inconsistencies in the wound description from visit to visit or week to week, only to finally determine that each clinician was actually talking about a different wound or wounds," Adams says.

Consider these additional wound documentation tips to help improve your records:

• Don't just check a box on a wound care sheet. A wound may look worse and actually increase in size when you use an enzymatic treatment to clean it out, for example. Describing the wound thoroughly rather than just measuring it can make all the difference.
• Document any interdisciplinary education or care you are engaging in. If you are working with a dietitian to improve a patient's nutrition, a physician to ensure certain aspects of her blood chemistry are in good ranges, or a diabetes care manager to help the patient manage her blood sugars better, you should include these details in the record.
• Support trauma wound coding. If a wound is designated in your diagnosis coding as a trauma wound, be sure to document the type of injury that caused the wound and the location of the wound.