How Streamlining Wound Documentation Improves Continuity of Care
Article originally featured on WoundSource
Continuity of care has always been the heart of practicing medicine and is especially important for wound care. Continuity of care in wound management equals better outcomes, cost-effectiveness, and satisfaction rates from patients. In providing continuity of care, wound care providers face challenges of time constraints to become acquainted with their patient and to build a rapport while simultaneously learning about their patient’s wound history. The electronic medical record (EMR) is vital in supporting continuity of care. These platforms enable the medical record to be in a central place for providers and clinicians to access, modify, and use to communicate about their patient’s progress.1
Encouraging the Team Approach with EMRs and Wound Care
Wound care clinicians are often encouraged to use a team approach. When patients are being seen by multiple providers in different facilities and places, it raises concern of fragmentation of care and can make the team approach difficult to achieve.2 To complicate the process, there are often many departments within a single setting that are responsible for providing care to the patient. Documentation is vital in communicating the plan of care across the continuum as a team. Closing gaps in communication and care is an ongoing problem that EMRs have helped to alleviate.1,2
EMRs and Wound Care Workflows
It is vital for providers and clinicians to demonstrate that patients are receiving high-quality wound care and that a proper plan of care has been created and is updated, as necessary. The wound care medical record documentation provides clinical specificity, medical necessity, and services rendered for billed services. There are key steps that drive compliance within the EMR workflow. For example, if a wound has stalled for more than two weeks, there should be a change in the treatment plan.3 In some specialized wound care EMRs, customizable alerts can help remind clinicians to take prompt action in notifying the physician of stalled healing. Flagged alerts can also be set as a reminder of necessary signatures, risk assessments to be completed, and weekly wound assessment.
EMRs can help to streamline workflows with the click of a button. EMR workflows represent how work is performed, not the protocols that have been established to do the work.4 EMRs with smart workflow synchronization are essential in meeting compliance within your facility. The documentation should contain the full scope of wound care performed and meet medical necessity criteria.5 The medical record sets the stage for medical necessity and continuity of care. The skin and wound documentation encompasses a variety of patient data to reflect the wound status across the healing continuum.
Many EMRs now include patient portals. Patient portals have become an important part of patient engagement, and they encourage patients to participate in their wound care. The patient portal allows for communication between the patient and provider and for the patient to access information on their care. Secure messaging allows the patient to message the provider and vice versa with questions or concerns about the wound, which can in turn save time spent waiting on a call back from the wound care office and reduce trips to the provider’s office.5
With specialized care, it is challenging to close every gap in communication and wound care. Patient care is enhanced when all providers communicate and when patients are provided with an opportunity to participate in and ask questions about their wound care. The use of EMRs in many health care settings has facilitated better communication between clinicians and has allowed for better patient care.
1. Sudhakar-Krishnan V, Rudolf MC. How important is continuity of care?. Arch Dis Child. 2007;92(5):381-383. doi:10.1136/adc.2006.099853.
2. World Health Organization. The Ljubljana Charter on Reforming Health Care, 1996. https://www.euro.who.int/en/publications/policy-documents/the-ljubljana-.... Accessed January 21, 2021.
3. Iqbal A, Jan A, Wajid MA, Tariq S. Management of chronic non-healing wounds by hirudotherapy. World J Plast Surg. 2017;6(1):9-17.
4. Hess CT. The value of smart workflows in a specialty electronic medical record. Adv Skin Wound Care. 2014;27(12):576. doi: 10.1097/01.ASW.0000457185.30748.ff.
5. Hess CT. Drive compliant documentation standards with a specialty wound care electronic health record. Adv Skin Wound Care. 2018;31(4):190. doi: 10.1097/01.ASW.0000531164.93924.4b.
6. Heath S. Patient engagement hit. xtelligent healthcare media. What are the Top Pros and Cons of Adopting Patient Portals? Accessed January 5, 2021.