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Introduction

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Wound care clinicians must understand that today's medical record serves as an instrument for demonstrating their ability to plan, coordinate, and evaluate patient care. The patient's chart, which was once used simply to measure patient outcomes, now may end up as evidence in a malpractice claim or used by an insurance company to confirm or challenge the level of service billed.

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Documentation in wound care, as in all areas of clinical practice, is critical for reimbursement. The medical record is the primary method of communication between members of the health-care team. Documentation of patient outcomes and responses to treatment are key for evaluating treatment interventions. Demonstrating "the need for skilled/professional intervention" by a wound care professional must be evident in the documentation regardless of the payer source.1 To ensure payment, a comprehensive individualized plan, indicating the wound problem and goal of treatment, must be in the medical record. While multiple models of documentation exist, one comprehensive source useful in wound care is the Guide to Physical Therapist Practice.2 This American Physical Therapy Association (APTA) publication recommends a five-stage management system—examination, evaluation, diagnosis, prognosis, and intervention—that supports third-party reimbursement.

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PEARL 33•1

Accurate and complete patient outcomes must be documented in the medical record.

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Treatment of wounds alone does not guarantee payment. Medical complexity, wound chronicity, and collaborative efforts from other members of the wound-care team should be reflected in the medical record. As the health-care industry continues to move toward cost-containment strategies outlined in the Balanced Budget Act of 1997, management of and focus on cost-effective functional outcomes is mandatory.

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This chapter identifies risk-assessment tools and provides documentation guidelines and examples of history and physical examinations, wound evaluations, and ongoing treatment interventions. General recommendations for billing in different practice settings also are reviewed.

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Interdisciplinary Documentation

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Pen-and-paper documentation is quickly becoming history. Today's documentation forms include, in addition to the old standby of handwritten notes, telephonic, photographic, and computer-generated correspondence. Regardless of the method of documentation, it is essential that guidelines be developed to assess clinical efficacy and cost effectiveness.

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Keeping in mind that the practice setting may vary, wound prevention and treatment are best addressed by a team of experts. Teams may consist of any combination of diabetic educators, dieticians, nurses (Wound Ostomy Continence Nurse), nurse practitioners, occupational therapists, orthotists, pedorthists, physical therapists, physicians, physician assistants, and podiatrists. Physicians of any specialty (dermatology, endocrinology, family practice, infectious disease, orthopedic surgery, plastic-reconstructive surgery, physiatrics, or vascular surgery) may be involved in wound care. The physician with the wound care interest, regardless of specialty, will function as the coordinator of care, using the expertise of other team members to accomplish the wound care goals. Professionals involved in wound care will perform a variety of functions, such as the following:

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  • Diabetes educator. Patient/caregiver education related to diabetes management

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