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  1. Hess, Cathy Thomas BSN, RN, CWCN

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WOUND CARE DOCUMENTATION has come a long way with the implementation of wound care-specific electronic medical records (EMRs). Today, we can enter data about the patient and corresponding wound information and provide that information in a secure fashion to collaborating healthcare professionals.


The EMR's interoperability allows collaborating healthcare professionals greater access to the patient record. Being able to download and store patient diagnostic studies makes it easier to diagnose and treat the patient in a coordinated manner. E-prescribing is also widely used within the EMR so prescriptions can be sent directly to pharmacies.


Another important function of the EMR is clinical decision support alerts. When clinical decision support is applied effectively, it increases quality of care, enhances health outcomes, helps prevent errors and adverse events, improves efficiency, reduces costs, and boosts provider and patient satisfaction.1 A standard methodology of wound measurement and tissue analytics can also be incorporated in the specialty EMR to help clinicians understand the wound healing process.


The EMR can capture assessment data using discrete data fields, which is critical to support the regulatory and quality mandates to improve quality, safety, and efficiencies. It's also imperative for accurate reporting. Integrating evidence-based guidelines and templates, standardized dropdown lists, and lookup tables can ensure quality data captured to support a meaningful platform. Developing core reports, generating quality reports, and utilizing the data to improve patient and facility outcomes can improve quality, safety, and efficiencies. Implementing three smart methodologies can enhance wound care and improve practice.


Support optimal workflows. Review current processes, documentation components, and data flows to identify gaps in best practices and guide recommendations for improvement in the clinical and operational workflow.


Capture accurate documentation. When clinical and financial outcome data are documented in the EHR, the data can be used to advance critical pathways, improve product formularies, validate contract fees with payers, improve patient and clinician satisfaction, and comply with federal mandates.


Ensure robust data reporting. Collected data reveal trends across wound and patient types, and clinical practices and operations. The data also allow comparison of clinical, operational, and financial outcomes through the data stored in the EMR system. To effectively interpret the report, it's important to understand the report requirements, as well as the data inclusion and exclusion requirements.


The healthcare industry is constantly evolving and becoming more accustomed to the EMR guiding process. Examining and continually updating processes is the key to successful documentation and reimbursement. Consider introducing the following enhancements to improve efficiencies:


* a scheduling module to coordinate patient visits and productivity


* patient and provider portals to engage in the quality metrics


* secure e-mail exchanges for coordination of care


* smart EMR features to meet the needs of all practicing clinicians as well as patients who may access their defined information


* clinical decision and practice management tools to alert the user to medication errors and adverse drug interactions and to track diagnostic study results and patient follow-up


* interfaces to pull data in and out of the system and clinical and operational compliance and audit mechanisms


* compliance with accreditation and certification standards


* audit trail to identify work performed through documentation


* reporting for outcomes and benchmarking.



By continually reviewing and updating documentation processes, clinicians can achieve better patient outcomes.




1. Agency for Healthcare Research and Quality. Clinical decision support. 2015. https://http://www.ahrq.gov/professionals/prevention-chronic-care/decision/clinical/index.html. [Context Link]