Today's Wound Clinic - Spring 2008 - (Page 26)

intech Get the Facts: Utilizing a Comprehensive Wound Clinic Documentation System Dot Weir, RN, CWON, CWS cards. As numbers grew in the system, that data enabled entering the world of clinical trials, providing the sponsors with up to date information of potential numbers of specific patient types that would qualify the center for certain trials. Fast forward to 2006, now at a new center that was designed with efficiency in mind. With computers in every treatment room as well as three out in the clinician work area, the facility launched into the world of a true electronic information system which has revolutionized how to achieve the facility still does choose to print certain documents and file them in charts for easy access and reference. At this point in time, the center’s Health Information Management Department (HIM) and coding department still require that physician providers continue to dictate a note in the system although WoundExpert will indeed generate a complete physician note.To legally utilize that, however, the physician would need to be the person putting that data into the system. In the flow of the authors clinic it has not gotten to that point yet, though many have. In the context of this article, it would be impossible to thoroughly describe all of the processes that the system provides. For further information, refer to their website WoundExpert.com. However, listed are some the author’s favorite features: Documentation. For the centers choosing to utilize WoundExpert for their physician documentation, it is designed in the familiar Subjective/Objective Assessment Plan (SOAP) format, based on the preferences of the majority of its physician users. It includes a history and review of systems, with tabs identifying sections including chief complaint, history of present illness, past medical and surgical history, allergies, and past family and social history, enabling each section to be updated as needed and as change occurs.The system then allows the physician to add a note related to any positive complaint or past diagnosis. Similarly, the physical exam is divided out into core systems with physician defined templates and systematic flagging of abnormal evaluations to generate an accurate and updatable problem list. As a result, the appropriate ICD-9 codes are automatically identified. For those desiring it, the system also provides complete procedural information with accurate accompanying CPT-4 codes to assure accuracy in coding and billing. Additionally, as decisions are made for diagnostic and medical care, the system T he comprehensive and ongoing documentation of the patient evaluation, the patient progress, and the events that occurred during each encounter at a center providing wound care is the critical basis of information capturing regardless of the system; electronic or paper. There are those components that one wants to capture, those that must be captured, and the usability of this information that drives one to evaluate the effectiveness of the methodology used and quite frankly, what will actually work for them. As this author entered the world of outpatient wound care, she started in a system where at least eight pages of written forms were filled out at the first visit, and probably five of those on an ongoing basis with each patient visit. Comprehensive it was, but time efficient, it clearly was not.The attempt to gather any usable data was virtually impossible, completion of the charting was most often totally completed the next day, or when the clinicians had time, and everyone was buried in paper. And so it was that in 2003, staff entered the world of semi-electronic data management, and the author’s three centers finally were interconnected via the WoundExpert System, in one of the early versions provided by Net Health Systems. The clinics early use was not a point-of-use system. Alas, the author’s facility continued with the paper charting, and had a person whose role in totality was to enter the data retrospectively. Not ideal, but it gave an excellent start in and appreciation of the usability of the information that a system such as this can provide about centers, patient mix, payer and wound type mix, as well as healing times and rates. It allowed tracking referral sources and trends, and even generated a mailing list for holiday Spring 2008 Today’s Wound Clinic “There are not dollar values that can be placed on it, but the details provided, which allow one to constantly evaluate care provided for patients is priceless.” same gathering of critical information, meeting all regulatory requirements, with the potential now to provide referral sources, home care and longterm care partners, and coding department with the necessary documentation to efficiently and effectively provide care and share the information necessary to keep the patient in a true continuum of care. The WoundExpert system has evolved and is currently used by clinicians and organizations all over the US. It is this author’s opinion that this EMR has passed exquisite scrutiny from a security standpoint, a comforting fact in the era of HIPPA requirements. At this author’s center, utilization of its completely customizable components from scheduling to documentation has grown exponentially, but the 26 http://WoundExpert.com

Table of Contents Feed for the Digital Edition of Today's Wound Clinic - Spring 2008

Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

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