Where Wound Documentation Falls Short - And How to Fix it
Updated: Mar 30, 2021
If you ask three different clinicians how wounds should be measured in terms of length, width and depth, you will most likely receive three different responses. The lack of consistency regarding this most basic of wound assessment parameters is a barrier to monitoring and analyzing a wound’s progress toward healing. Inconsistent documentation does not end with basic wound measurement, it includes other components such as identifying the wound’s anatomical location, describing the actual wound tissue composition, and characterizing the significant co-morbid conditions that complicate or prevent wound healing - all which are exceedingly important elements in wound healing.
One of healthcare’s standing principles is, “If it’s not documented in the medical record, then it didn’t happen.” Inadequate documentation increases your liability risk, your risk of payment denials for establishing medical necessity, and your risk of federal and state regulatory citations. Gaps in wound documentation may include:
Inconsistent wound measurements from one assessment to another, if completed at all
Inaccurate identiﬁcation of the wound type
Incomplete or missing wound assessments, which are complex and require a standard, uniform structure
Wound management plans that do not reflect evidence-based best practices
Documentation which deviates from company policies
If you don’t make documentation a top priority, you may find yourself in one of your worst nightmares: defending yourself in court, paying a large settlement to a prospective plaintiff or slapped with conditional level deficiency by a surveyor.
Corstrata uses wound software that addresses and simplifies many of the common inconsistencies just noted. Our imaging software provides automated, uniform wound area measurement, from one clinician to the next, with a feature that highlights progression of wound healing through time. Our software detects wound composition differences by color, indicating various types of wound tissue. Our board certified wound specialists provide expert wound assessment with recommendations that reflect current evidence based, best practices and help to identify wound etiology, which drives the patient’s management plan. Corstrata’s software drives consistency and standardization of wound documentation that helps healthcare providers decrease their liability as well meet regulatory and compliance standards.