Wound Care Charting: A simple one page document

By: Lawrence 0. Kollenberg. D.P.M., F.A.C.F.A.S., C.W.S.

The purpose of this document is to provide the wound care Practitioner with simple, accurate documentation on one page that meets HCFA criteria, and medico-legal criteria for single and multiple wound type situations. The Practitioner is cautioned to check with their legal council and/or Medicare advisor to determine if this document meets their individual state’s criteria.

At the time of each patient encounter, the form should be labeled with the patient’s correctly spelled name (and clinic number if any). Vital signs should be monitored and recorded. A brief updated history about the wound and any problems associated with the wound or dressing materials should then be recorded. All CPT billing criteria requires that an update of significant past medical history changes be reviewed. If there are no changes, then the note should read “No changes in PMH from visit of 00/00/00” (the last visit recorded).

Any medication changes since the last visit should be recorded next, or a quick note stating that there are no changes in medications. Any adverse problems with medications can be noted in the comments section on the bottom of the page.

At the time of each encounter, the wound care provider should record documentation of the appearance of the dressing including contaminents and strikethrough, if any.

Upon undressing the wound, record the appearance, drainage characteristics, granulation, and location of the wounds. Drawing sheets and pictures of the wound appearance can be attached to this record.

Always keep the staging or Wagner’s classification of the wound the same as it was at the ORIGINAL visit.

By recording the current visit, last visit, and original visit size and depth, you will have an updated record to show progress of the wound site at all times, which will document the progress of your wound care plan. If there is no improvement shown after several weeks, then upon audit from HCFA and other agencies you may loose your reimbursement.

List the type of care being rendered including any wound debridement, cleansing agents and irrigation agents that are utilized at each visit.

All dressings that are applied, including primary and secondary dressings, will allow the care giver to know at a glance if this treatment protocol is effective or not.

Any prior dressings that are utilized should be listed so that you will be reminded at a glance of what has not worked for this particular patient.

Any special notes that are needed can be listed in the comments section.

Please call the Wound Care Institute in the USA at 305.919.9192 for a blank patient wound care form that corresponds with the above information.

1) Flshman, T.D., Freedline,A.: Wound Care Institute Newsletter, vol. 1, no. 1, Jan/Feb. 1996.
2) Provider Newsletters, Medicare Division Arkansas Blue Cross/Blue Shield.
3) Federal Register, HCFA Washington, D.C.

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