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Wound Documentation to Avoid Lost Revenue

Wound care is one of the top payment groups for PDGM but is the documentation good enough to support payment? Review of documentation needs to start on admission by reviewing discharge summaries and office notes to make sure that they address the wounds. In addition, the documentation as to why the wound care is a skilled need should be present. Patient unable to do wound care is not enough. Documentation to show the skilled need would be “wound care completed to left great toe. No s/s of infection but patient remains at high risk due to diabetic status. Skilled nurse visits to perform would care and assess wound status. Patient on bed to chair activity only.

Wound care documentation is a common area of scrutiny so it is important that the agency provide training to all clinicians that are responsible for wound care. CMS says that wound care documentation should include: “The size, depth, nature of drainage (color, odor, consistency and quantity), and condition and appearance of the skin surrounding the wound must be documented in the clinical findings so that an assessment of the need for skilled nursing care can be made.”