Capturing the Essence of The Wound Care Evalution

Documentation in wound care is critical for reimbursement. To ensure payment, a comprehensive individualized plan, indicating the wound problem and goal of treatment must be in the medical record. The American Physical Therapy Association’s (APTA) “Guide to Physical Therapist Practice” recommends the five-stage management system; examination, evaluation, diagnosis, prognosis, and intervention.

Wound care is usually best performed by a team of experts. Your team may consist of any combination of diabetic educators, dieticians, nurses, nurse practitioners, occupational therapists, orthotists, pedorthists, physical therapists, physicians, physician assistants, and podiatrists. The physician or advanced practice nurse will function as the coordinator of care, utilizing the expertise of other team members to accomplish the wound care goals. The team members conduct evaluations within their specific scope of clinical practice.
The examination phase of a wound consultation is assumed to be the most important aspect, particularly identifying any pre-existing signs or symptoms, relevant systems review and tests and measures. It is very important to identify all risk factors.

Crucial to the evaluation of the wound is identifying the cause of the wound to establish a diagnosis and prognosis. This allows the clinician to identify the class and severity of the wound by stage, thickness, or colors. In broad terms, wounds are lesions caused by trauma or surgical interventions, and all other lesions would fall into some sort of ulcer classification. However, the ICD-9 diagnosis coding system is a poor one when it comes to proper coding of ulcerations. Using ICD-9, it is not possible to properly designate mixed arterial/venous or inflammatory ulcerations, for example. In addition, a lesion, which began traumatically but persists in a non-healing state for many months, could be classified as a chronic ulcer. Medicare provides no guidance as to how to deal with these issues. For the rest of this article, the term wound to refer generically to all skin lesions, whether they would be classified as a wound or an ulcer in the ICD-9 coding system. Ironically, using the term wound and ulcer interchangeably in clinic notes can be cause of confusion and even lead to coding errors and should be avoided in clinic documentation.

In addition to determining a diagnosis, usually done by an advanced practitioner, documentation is needed as to the details of the wound appearance. The visit-by-visit wound evaluation is typically carried out by the clinic therapy or nursing staff. This provides the comparative data that, over time, details the progression (or lack thereof) of the wound. It is this ongoing evaluation and the documentation of such that provides the necessary data to support the advanced and ancillary treatment modalities which may be required. Thus, this documentation is vitally important to the patient and the clinic. Phrases such as, in my medical opinion are meaningless without objective data to substantiate medical necessity.

Wounds are dynamic and change over time. The evaluation of the status of the wound at each encounter enables us to set goals for management. If the goals are based on an accurate and complete evaluation of the wound, and the treatment is chosen based on that evaluation, then the clinical decisions should be appropriate for that patient.

Regardless of whether one uses paper or electronic data collection tools, information should be gathered in a systematic way to allow comparison from visit to visit. The following documentation points may provide guidance.

Components of the Wound Evaluation
Wound Etiology. Should be documented with each encounter.
Location. Documentation of the location can also support the etiology. For example, an ulcer documented over a bony prominence is indicative of a pressure ulcer, one at the medial ankle suggests venous, and plantar foot, of course a diabetic foot ulcer. In most settings, wounds are generally assigned a number. Consequently, when more than one wound is located in a general area, using descriptors such as anterior, posterior, medial and lateral, and so on can help to differentiate the individual wounds. Consistent terminology should be applied. Avoid using non-medical terms for location such as above, or below.

Wound Size. Wound measurements are typically done on a weekly basis. In a recent National Pressure Ulcer Advisory Panel (NPUAP) newsletter (Fall, 2007) the recommendation was made to measure wounds using the clock method, with the 12 o’clock to 6 o’clock (or head to toe) measurement being the length, and the perpendicular to that, or 3 o’clock to 9 o’clock being measured as the width. This method is counter-intuitive to some, because for some wounds the length may be smaller than the width. The alternative is to use the longest measurement as the length, with the area perpendicular to that measured as the width. The practical reality is that one chooses a method, makes that the protocol followed, and all staff consistently measure in the same manner. By convention, wounds are normally measured in centimeters. Some clinics measure in millimeters. There is no data to support that measuring in millimeters is more accurate since most rulers are centimeter based. The clinic should decide on a method and follow it.

Wound depth is measured as an absolute number accounting for the space measured from the base of the wound to the skin or epithelial edge. As an additional measurement, any undermining or sinus tracts present should be documented. The location of undermining can also be designated using the clock face technique (eg, 2 cm of undermining at 2 o’clock).

Stage or Degree of Tissue Destruction. Depending on the wound type, the accepted terminology for describing the depth of tissue destruction should be utilized. For example, the NPUAP staging system for pressure ulcers should only be used for pressure ulcers. While other diabetic foot ulcer grading systems are likely superior to the Wagner system, CMS uses the Wagner system as a criteria for hyperbaric oxygen therapy and so it continues to be used in wound center documentation. In general, whenever there is a validated grading or classification system, it is advisable to use it, but only as intended (eg, the NPUAP system can only be used for pressure sores, not for other wound types). The C.E.A.P. classification system can be used for venous ulcers. Other wounds can be simply documented as partial-or full-thickness.

Tissue Type. Documentation of the tissue type helps to define the treatment protocol. Necrotic wounds usually need debridement (depending on the vascular status), while clean wounds call for management of the environment. Commonly, clinicians will document the tissue type as an estimated percentage of the total wound space. Some facilities may have access to more sophisticated software, which can map out the percentage of tissue types from a photograph. However, most clinicians use the guesstimate method. Tissue types are generally described in terms of types of devitalized tissue, eschar, slough and fibrin, and then the remaining viable tissue.

It is difficult to quantify the amount of tissue, which is viable. In many documentation systems, the common descriptor for this is granulation tissue. However, granulation ought to refer to vascular tissue, that is, regenerating capillaries. What if the tissue is pale, flat and non-granulating? The wound care industry lacks a universally agreed upon vocabulary for tissue descriptors. Even material such as slough can be described in a myriad of ways. While each clinic can establish a vocabulary they find appropriately descriptive (eg, pale, dusky, clean but non-granulating, etc.), it would benefit the field to establish a universally accepted set of terms, which would mean the same thing from one facility to another.

It is critically important to document any exposed structure present in the wound such as muscle, bone, tendon or fascia. These have implications when billing debridement procedures, and grading or staging a wound.

Wound Edge. Different than the periwound skin, the evaluation and documentation of the condition of the wound edge places focus on an area of the wound that is often overlooked. Being tuned into rolled edges or epibole can demonstrate the need for specific treatments such as debridement of the edge to enhance wound healing by stimulating an edge effect or migration of epithelial cells.

Periwound Skin. The condition of the skin surrounding the wound can signal the need for a change in exudate management. Intact undamaged periwound skin indicates adequate exudate management. Macerated or denuded skin tells a different story, leading the clinician to make a choice in dressing management that can better absorb the wound exudate. Additional cues to management issues include callous along the periphery of a plantar diabetic foot ulcer, indicating additional continued trauma and probably the need for improved offloading or compliance with the offloading prescribed.

Exudate. The exudate or drainage from a wound needs to be described not only in regards to quantity, but quality or character and color also. Often the only options include serous, sanguineous, or the combination sero-sanguineous, or purulent or green. The latter two options conjure up a mental picture of the byproduct of bacterial growth when in actuality it may be an expected appearance of the treatment in use. Consider the wound that has been treated with a hydrocolloid or some other topical which leaves a liquefied residue behind. Similarly, wounds that are post application of a bioengineered tissue or after treatment with a papain-urea-chlorophyllin copper preparation such as Panafil® (HealthPoint, Dallas, Tex) which has a deep green color. Adding the choice treatment residue can alleviate that ambiguity. Providing the ability to type or write in specific descriptors related to the color or character (clear, cloudy or opaque) can further define the exudate.

Odor. This is very simple. There is either odor or there is not, and the odor can be mild, moderate or strong. Either way, the very presence or absence of odor needs to be documented for comparison at subsequent evaluations.
Pain. The patient’s perception of their pain. Use of the commonly accepted visual analog scale to determine a patient’s pain level should be employed. Pain specific to the wound should be assessed. In addition, generalized pain may be considered the fifth vital sign, so pain may need to be collected in more than one area of the chart. There are standardized pain assessments which assist in determining the effect of pain on activities of daily living, as well as worst, best, and ideal or goal pain levels which can be used to structure pain interventions.

Standardized assessments
There are validated tools, which can be of assistance in assessing wounds. Barbara Bates-Jensen’s BWAT is one of those. Whatever method is chosen, staff should be trained to use methods consistently, and this can be a considerable challenge.
There are two important therapeutic considerations when it comes to wound documentation. Certain wound characteristics drive clinical decision-making. For example, maceration, foul odor, a large volume of exudate or necrotic material ought to drive certain clinical decisions with regard to dressing product choices. Getting these descriptors right will assist with making the right clinical decisions.

The second therapeutic consideration has to do with assessing wound progress. During assessing of the wound progress, professionals generally rely on wound measurements. However, one could argue that before a wound begins to decrease in size, other parameters improve. A wound originally full of slough with a large amount of purulent exudate which has now become well granulated with a minimal amount of serous exudate, could be seen as improved, even before measurements have decreased. A standardized method of wound assessment would allow one to identify these improvements prior to the change in wound size.
The specialty of wound care would be benefited if there was agreement to a universal assessment tool. This would be a substantial challenge as an industry since many organizations have historical data which would be affected by changes in collection methods. However, standardizing the wound assessment process would have the considerable benefit of making data comparable from one facility to another, and would likely facility clinical research.