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Documentation Tip of the Week: Wounds

Posted on Wed, Aug 26, 2015
Documentation Tip of the Week: Wounds

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

  1. Always document the “Present on Admission” status for decubitus ulcers. Doctors must document the wound and location. Other knowledgeable providers (i.e., wound care nurse) can document the stage.
  2. Gangrene should be specified as wet (infectious) or dry (ischemic).
  3. Always document the possible link of diabetes to wounds.  If patient is diabetic, then the provider should document the link. Importantly, the physician must also UN-link diabetes to wounds when this is appropriate (e.g. trauma causing a wound unrelated to DM)
  4. Always document if the wound is a complication of injury, surgery or a device. The provider must document the causal link if possible.
  5. When getting the link, the physician must document "due to" or "secondary to." The physician should not write
    • wound
    • surgery 2 weeks ago
    • mesh infection
Instead, the physician should document: “wound secondary to surgical mesh infection.”

Dr. Timothy Brundage

Timothy Brundage, MD, is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips or ask him about specific documentation issues by emailing him at DrBrundage@gmail.com.


 

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