Health Information Management

Tip: Conduct chart reviews for ulcer documentation opportunities

CDI Strategies, December 10, 2009

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Since physicians don’t always document pressure ulcers, carefully conduct investigations of alternative clinical indicators from their notes, writes Helen Walker, MD, RN, vice president of clinical quality at FairCode Associates, LLC, in Towson, MD, a healthcare consulting firm specializing in DRG and coding audits in the October 2009 CDI Journal article “Improve pressure ulcer documentation.”
 
“You are more likely to find nurses or wound care specialists documenting the pressure ulcers since they are directly involved in treating them,” Walker says.
 
So be sure to examine the following:
  • the nurses’ notes from the nursing home patient transfer forms
  • the emergency department record
  • the nursing admission history and database
  • the skin assessment
  • the daily nursing care notes
  • the wound care specialist’s notes
In addition to the existence of the pressure ulcer, look for documentation of its stage. The physician’s orders may provide a clue. You may find an order for an air mattress, a turning schedule, a wound care consult, or wound dressings.
 
For a sample pressure ulcer query form, ACDIS members can download the article on the Web site, www.cdiassociation.com.



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