Organization revamps wound care documentation policies and procedures
Chronic wounds not only affect millions of patients, but they also represent a significant burden to the healthcare professionals who are trying to manage and assess them.
There are many roads to wound care right now-physician offices, wound care facilities, hospitals, outpatient clinics, and home care-and all clinicians like to think that, whenever possible, they're delivering best practices to their patients and staff, but effective documentation as part of an already busy day may not yet be integrated into routine practice.
Plus, new legislation removing reimbursement for never events and the new mandatory reporting of adverse events means your facility might find itself shouldering hefty sums for hospital-acquired conditions, which is what wounds present on admission will be considered if they lack adequate documentation.
Wound care documentation standardization
Such was the case for Prime Healthcare Management in Ontario, CA, before it standardized its wound care documentation. Prime is a 14-facility healthcare system consisting of more than 2,000 acute and psychiatric beds. After discovering its documentation was less than optimal, Suzanne Richards, RN, MBA, MPH, FACHE, chief clinical officer for Prime, took it upon herself to spearhead a revamping of the organization's wound care documentation policies and procedures.
Richards says she found two main areas that were causing issues: Nurses weren't documenting or were merely giving a vague description of the wound, and all of Prime's wound care documentation was only in pictures. "[Nurses] would just put Stage I, II, III, or IV, but you wouldn't know the dimensions of the wound, or we would have the description sometimes say ‘the size of an orange,' " she says. "But what is the size of an orange and why are we equating a wound to a piece of fruit? We also had a picture when the patient arrived and another picture a few days later. The documentation would say that the wound was getting better, but on the picture it would look like the wound was getting bigger because the camera was closer to the wound the second time. We were doing very subjective anecdotal notes, and we did get cited for inadequate documentation."
Richards says the organization standardized its wound care documentation across the board. It decided what the documentation form would look like, updated its policies on picture-taking so that pictures would not be lost or misplaced, and standardized staff education. According to Richards, the new documentation form is very comprehensive and includes:
- A picture of the wound
- Measurement of the wound
- Stage of the wound
- Date and time
- How close the camera is is in relation to the wound, and the photographer's name
- Physician's signature
- If/how the wound is going to be treated, and by whom it will be treated
Why documentation is important
The change in legislation given by CMS that removes reimbursement for hospital-acquired infections and hospital-acquired conditions is in large part a result of hospitals failing to document wounds present on admission, says Mary Ransbury, RN, BSN, PHN, CWON, corporate director of skin and wound management, infection control, continuing medical education, and in-house education for Prime. Ransbury played a large part in implementing Prime's standardized wound care documentation, processes, and policies. As a wound, ostomy, and continence nurse, she functions as a corporate clinical resource to facilitate and organize clinical teams to review, organize, and strategize opportunities to improve quality and patient outcomes. This is done by developing systemwide programs to assess, document, communicate, treat, and reassess patients at risk or with preexisting wound and skin conditions.
Ransbury says that proper documentation is important not just because of the potential cost associated with hospital-acquired conditions, but also because of legal issues. "Elder abuse can involve any patient that develops a pressure ulcer during the course of their hospitalization, and elder abuse claims have no capitation, so they can sue for millions," she says.
Streamlining your documentation and processes will optimize patient care, which is something surveyors are looking for, Ransbury adds. "Optimizing better assessments early on will enhance the treatment plan because you have more people aggressively treating during the entire length of stay. Staff will be able to pick up charts during the patient's entire course of their care and know exactly what type of care the patient has been given. Streamlining will also enhance better assessment skills that will optimize earlier interventions."
According to Ransbury, the most common reason why hospitals get cited for inadequate documentation is lack of consistency. Surveyors want to see that your policies are being followed; that policies state that you take a daily assessment, measurement, and photo upon admission, after a change in condition, and at discharge; that the method you use is consistent from nurse to nurse; and that you're communicating that process.
Innovations in wound care documentation
Prime's newly developed form speaks heavily to the condition of the patient's skin, says Ransbury, and the form is used by everyone throughout a patient's hospitalization. Regardless of whether the patient is a direct admission or a transfer, the same documentation tool is used from the time he or she enters the building to the time of discharge.
"When the assessments know there is a condition of the skin, it gives a certain message to the nurse that they cannot bypass," says Ransbury. "So everybody is looking at one tool, one process, and their communication is streamlined into one location."
Prime incorporates the same tool into its physician order section so physicians can view the documentation from the nurse, including a photo of the wound, and identify whether the wound was present on admission and what treatments are in place.
Ransbury says that in standardizing Prime's wound care documentation, it was important to look at ways to encourage nurses to provide better photo documentation. To do so, Prime came up with circular measuring devices, which are basically color-coded rings that allow the photography to be enhanced because of the contrast of the photo rings. "I'm big on photos," says Ransbury. "They're critical. They speak a thousand words. Most of the time a nurse's assessment goes where it needs to be, but a photo helps support it."
The campaign took the "routineness" out of photography by making it more fun and enjoyable for the nurses, says Ransbury. "It really allows some visual scaling of the room so there's no discrepancy," she says. "By having something circular, it can't be cropped out, it allows the photographer to be automatically focused in on the size of the wound, and it's consistent. And that consistency has been very helpful."
Tapping into resources to educate staff and overcome barriers
An important part of implementing new policies and procedures is educating staff on how those policies and procedures are going to affect their day-to-day work and why they are important. Prime held many courses on documentation that needs to be in the medical record, including the potential ramifications for failure to document. "We went out and explained why this info was important, and leaving the info out would just leave issues for them when they're trying to justify it in court," says Richards.
Prime also incorporated the standardization into its general orientation. "We hold hour-long sessions to educate all new nurses of the methodology and the critical necessity of early intervention, early assessment, early treatment, and maintaining consistency," says Ransbury.
Of course, implementing new policies and procedures means a greater demand on time and priorities, potentially provoking resistance from staff. Richards says the biggest barrier has been adding to nurses' already busy schedules.
"With nursing care, when you've got five patients and they're in for a certain type of diagnosis, you've got to focus on that certain diagnosis and some things get placed as a second or a third priority, so we needed to demonstrate that wound care was a top priority to them in addition to the diagnosis they're in there for," she says.
As a way to encourage staff buy-in and participation, Prime developed "champions"-nurses who take an active role in the decision-making process. "We actually wanted their buy-in and participation, and it was really them that developed the educational programs," says Ransbury. "They also came up with acronyms like cleanse, protect, replenish, and we did a campaign where we made an award system and recognized particular staff members who went above and beyond."
Another key factor in educating staff across a 14-facility health system is the organization's quarterly meeting in which all of Prime's facilities get together to discuss best practices. "This has been key," Ransbury says. "So where we may have a weak facility, we quickly bring the staff up by working together collaboratively from all other hospitals and pull and tap into those resources."