Frustrating: Undocumented Wounds
Im having an issue at my agency where my clinicians are finding wounds during the assessments, adding them to the orders, and arranging their visits according to the wound care they are doing. Which is great, only there is no MD documentation of the wounds. And many times, the clinicians know that the wounds have never been assessed by a physician (patient falls after being d/c from acute care and now has several skin tears at the SOC, for example, or patient is found to have a stage one DU at the assessment, so the SN initiates wound care)... yet, they want the wounds coded. I'm aware that nothing gets coded without MD documentation, but this scenario is becoming more and more common and i am finding myself getting so frustrated. Mainly because this results in a massive waste of my time. I see a wound mentioned in the orders, so i have to dig and dig and dig to see if I can find supporting in documentation to code it, and nothing exists. I cant even tell you about the copious amount of time I waste every day doing this. So so frustrating. This is by far, the very worst part of coding for Home Health, in my opinion. I've mentioned this to clinical managers and no one really seems to feel like it is huge deal. So it got me curious if anyone else experienced this where they work... if so, how do you deal with it, or how has it been resolved? I just cant continue to spend 30 minutes on each chart searching for physician documentation of a wound that just does not exist. It's making me crazy and slowing me down. I welcome any and all suggestions.
Comments
documentation is a violation of coding rules. Where are the oprders coming
from to treat these wounds? If the clinician is calling the physician for
wound orders they can verify the type of wound and document it along with
the orders. If the clinician is writing orders on the plan of care for
wound care without talking with the physician, that is a serious Condition
of participation violation.
Copy the first page of the Officiial Coding Guidelines that describes the
requirement for only a physician or other personal legally authorized to
diagnose for the Clinical Managers and the clinicians. along with a written
description of the issue. Also discuss this issue with your supervisor, If
the Clinical Manager and/or your supervisor is not willing to address this
issue with the clinical staff, report the issue to your agency's
compliance officer and/or the agency Administrator (depending on your
agency policy).
Judy
Judy Adams, RN, BSN, HCS-D, HCS-O
Adams Home Care Consulting, Inc.
97 Perriwinkle Place
Durham, NC 27713
office Phone: 919/294-6674
Email: jradams31@gmail.com
we get frequent referrals from has an MD that wants to call everything a
venous stasis ulcer. and none of the patients have underlying PVD ,
etc....so it makes for a nightmare to get documentation. I am frustrated. I
didn't think you could diagnose VSU without underlying disease. ?