Wound documentation
I'm interested in hearing what other organizations are doing to ensure wounds are documented by the provider (query, smartphrase, co-signed note, shared note, etc).
I appreciate your feedback.
Deanna Payne BSN, RN, CCDS
RN Clinical Documentation Quality Assurance
Kettering Health
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Hello Deanna, we are actually working on a new process for our Wound queries as we typically send ALOT of them. The process is similar to one we have in place for malnutrition queries. It is in a sense a query, but it is automatically sent from the Wound Care Nurses documentation. It states that the wound care nurse has identified the following and pulls forward the wound care nurses assessment and plan of care. Then it compliantly asks the provider to assign a diagnosis and provides drop downs for them to choose the type of wound (ex. pressure, non-pressure) and specify location, and also includes a choice of "other" where the provider can free text their answer. Each tissue injury site will have a separate section so that all can be answered individually. Once the provider answers, it becomes a progress note (permanent part of the medical record) and we can code it from there. We are starting with HAPIs to ensure the process works well and then moving to all pressure injuries! This should save CDI alot of time and streamline the process. Thanks, Skyler
Hi Skyler,
Thank you for your feedback. May I ask what software you use to generate the query? Also, is the wound care nurse documentation pulled from a note or a flowsheet? I appreciate your help.
Deanna
Hi, three years ago, I met with every wound nurse within the organization and shared with them what information was needed to adequately capture the patient's wounds. We worked with EPIC to have the wound care notes pulled into the physician's notes as part of their record. We also did the same with the dietary assessments.
The physicians then acknowledge and support treatment measures. THis has made a world of difference.
Tracy Gapinski, BSN, RN, CCDS
Hey Deanna, We use Allscripts/SCM to generate this "query" - the clinical information is pulled from the Wound Care Nurse's Initial Assessment which includes the Wound Care nurses documentation stage, site, description of tissue injury.