Documentation of pressure injuries
A question regarding physician sign off on whether an RD assessment can be used for coding was addressed in Coding Clinic 1st qtr. 2020, page 4). Their response" Your hospital may develop a facility-based policy to address whether documentation that is signed-off by the patient's provider is allowed to be used for coding purposes."
At our facility we are exploring better options for the provider to receive real time notification of a patient's nutritional assessment and validated pressure injuries. We have implemented a process that all suspected pressure injures are WOC validated and once validated a notification is sent to the provider. Unfortunately this notification seems to end up in a long list of notifications and we can not be assured the provider has read the note - basically we know this because we still have to query for documentation of the pressure injury.
Based on Coding Clinic's response we would like to explore the option of having the provider sign the WOC validated pressure injury report and pull the information into his progress notes so he can address it in his plan of care regarding the pressure injury. We believe this will help assure early awareness and ability of early intervention by the provider of a pressure injury and ultimately reduce the need for a query.
I was wondering if any other facilities would be willing to share their documentation practices for provider documentation of pressure injuries. Is anyone allowing a provider signature on an RD or WOC assessment to be used for the final coding ? I do think more than just a signature would be needed - some type of physician attestation would be necessary, along with it added to the problem list , etc.
Thank you - anxious to hear your thoughts and practices.
Comments
Hello there- did you happen to receive any feedback regarding this topic? Our facility is also interested having physicians sign the Wound Care note and the ability to code from the signed note. I like the idea of pulling a portion of the wound care note so it is a part of the progress/discharge note. Would love to hear what your team ended up implementing. Thank you Nichelle