Documenting Your Success

Documenting Your Success here is an ancient Chinese proverb which says, the palest ink is better than the best memory. This issue is about medical documentation. These days, documentation may or may not be done with ink, but there is no question about the importance of providing a record of the care we have provided. The issue of documentation is enormously complex. The topic includes not only how information is to be collected (with paper, electronically or even some mixture of the two), but also how information will be used. To begin, we will take a 30,000-foot view of documentation, that includes general principles—which must be observed, and the rules that govern physician and facility documentation. Do you know where your medical records are? The answer can be more complex than one might think. In a modern clinic, the medical record, rather than being a collection of paper, might consist of many different types of data that are, stored in several ways. For example, how are the digital photos identified as part of the legal chart? In fact, wound photography can become an important legal discussion. Val Sullivan will discuss what types of equipment work best for documentation and the litigation process, with nurse legal consultant Mary Bruno. With regard to data, how do data get into the medical chart? Do you have an audit system to ensure the quality of the data in your charts? Moira Hayes will discuss documentation compliance programs, which are critical to having a successful clinic. Have you thought about transitioning to an electronic medical record system? We will take a close look at three options for documentation. Dot will discuss how she uses NetHealth’s WoundExpert System, (Pittsburgh, Pa), Caroline will discuss how she uses Intellicure’s Electronic Medical Record, The Woodlands, Texas, and N. Blair Hughes, MHS, PT, CWS will review the option provided by Wound Care Strategies, Inc., Harrisburg, Pa. In our InBusiness section, Kathy Schaum will discuss how Medicare contractors include documentation guidelines in their Local Coverage Determinations and Articles, using examples from actual wound care related LCDs and Articles. Would you like to sound like an expert? You will after you read Heidi Mueller’s InFluence section. She will tell what (and when) to copy to your referring physicians, and what to include in progress reports. You are sure to enjoy our featured wound care center, the O'Connor Wound Care Clinic, and the Q&A with Medical Director Peter Schubart, MD, PhD. Lastly, don’t miss a preview of our next online survey in Exit Polls. Our Medical documentation will determine the success of your facility. No topic may be more important to Today’s Wound Clinic. We think this is our best issue yet, and we hope you agree. Caroline Fife, MD, FAAFP, CWS and Dot Weir, RN, CWON, CWS