Wound Care Documentation

mdomineseymdominesey
edited May 2016 in CDI Talk Archive
Has anybody created any presentations or resources regarding wound care documentation? I have been asked to work with the wound care center to help them document their procedures and evaluations better.

Any tips or tricks or sample notes or presentations you can offer would be most appreciated!

Thanks!

Mark


Mark N. Dominesey, RN, BSN, MBA, CCDS
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital

5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
mdominesey@sibley.org

Comments

  • kshumpertkshumpert
    edited May 2016
    Are you going to working with them regarding inpatient or outpatient?

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8152

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela


  • mdomineseymdominesey
    edited May 2016
    Sorry! I should have mentioned this! I will be working with them for both inpatient and outpatient.

    Mark


    Mark N. Dominesey, RN, BSN, MBA, CCDS
    Sr. Clinical Documentation Improvement Specialist

    Sibley Memorial Hospital
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    Mdominesey@sibley.org


  • kshumpertkshumpert
    edited May 2016
    I went over present on admission and debridement documentation. I also did an over of inpatient reimbursement. I then showed the difference with a Stage 3 pressure ulcer POA and U (to show insufficient documentation) and excisional versus non-excisional debridement and the potential for reimbursement. I know there are some different requirements that they have for debridements alone on the outpatient side. I think that on the outpatient side that there is some type of coding rule about the number of debridements that can be done on an extremity when the wounds are within a certain distance from each other. I know they use some different terminology than we do such as selective debridement when the debridement is very superficial. I may have some screenshots of the inpatient things I did and I can check with our chart auditor (she does a lot of the outpatient work) about the outpatient wound care if you have any questions.

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8152

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela

  • mdomineseymdominesey
    edited May 2016
    Great ideas. Screenshots would be most appreciated. My email address is mdominesey@sibley.org

    Thanks so much!

    Mark N. Dominesey, RN, BSN, MBA, CCDS
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital

    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    mdominesey@sibley.org

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