Using a checklist form to document wound care can make the task easier and faster—and help ensure that you’ve captured all pertinent data needed for assessment, reimbursement, and legal support. But the form itself may not be comprehensive; some important fields may be missing.

Recently, we at Wound Care Advisor received a question from a clinician who was having trouble deciding how to code a patient’s wound in her hospital’s electronic health record (EHR). Her patient’s specific wound and tissue types weren’t available options in the dropdown menu on the software system. Luckily, on investigating, we discovered her system provided the option to override the checklist and add comments in a notes section.

Perhaps you’ve been in a similar position. If so, did you ask for help? Did you find out about an override option? Or did you just choose from the only options offered?

Whether it’s done with pen and paper, a computer mouse, a checklist, or a narrative form, documentation in the medical record is considered a legal document. Choosing an option that isn’t clinically accurate because it’s the only option you think is available doesn’t protect you from legal issues or even healthcare fraud.

Think of the problems that could arise from this. Suppose, for instance, you classify a dermal lesion as a pressure ulcer; the computer software recognizes the pressure ulcer code and bills Medicare for pressure ulcer reimbursement. Hospitals are reimbursed at a higher rate for pressure ulcers than for dermal lesions, so your documentation could constitute Medicare fraud.

Here’s another scenario: You code a wound as a skin tear in the EHR, but the skin tear actually is a pressure ulcer. Subsequently, the patient develops a wound infection and dies. Your facility is sued for wrongful death and you lose your professional license due to inaccurate documentation.

Checklist tips

To make your wound care checklist and EHR documentation the best it can be, follow these tips:

• Notify management about complications or challenges with current documentation forms.
• Ask the wound care committee to review the forms and generate a wish list to present to the information technology department.
• Investigate possible use of a commercial specialty wound documentation module.
• Advocate for staff training on the proper use of forms and electronic records, as well as the legal implications of wound care documentation.
• If your computer system can’t be changed, work with management to find an alternative method for proper wound documentation.

In addition to commercial wound documentation modules, consider free resources. For example, you can download a pressure ulcer documentation form from the Agency for Healthcare Research and Quality. Having the best possible checklist or documentation form helps protect you from legal action, ensures that your facility obtains proper reimbursement and, most importantly, promotes optimal patient care.

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Wound Care Advisor, Editor-in-Chief

 Cofounder, Wound Care Education Institute

Plainfield, Illinois