Viewing posts categorised under: Wound Care

Wounds and OASIS Documentation

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Clinical Documentation Improvement, Educational Videos, OASIS, OASIS-C2, Wound Care

Wounds and OASIS Documentation Presentation

Wounds and OASIS Documentation Key Facts

 

Upon completion of this session, attendees will be able to:

  • Documenting surgical wounds
  • Identifying and documneting skin ulcers
  • Documenting other skin lesions and skin alteration
To watch the Wounds and OASIS Documentation live presentation fill out your name and email address

Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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How do I Properly Document Wound Care?

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Coding, Wound Care

Wound Care coverage must have specific physician orders for one or all of the following:

  • Instruction/teaching on the wound care
  • Performance of the specific wound care
  • Assessment as to wound site progress/complications
NOTEDocumentation must include type of wound with size, depth, drainage, odor, color, skin condition, with specific interventions provided as ordered by the physician. Wound care is under significant scrutiny.
  • A stasis ulcer with a status of early/partial granulation adds two points to the Home Health Resource Group (HHRG). A “not healing” status adds 11 points. Auditors will look for the specific documentation to support each.
  • In addition, an early/partial granulation adds 25 supply points and not healing adds 36 points. (CMS –Regulation number 1560-F)
Note: Inadequate venous circulation to the affected area should be clearly documented. No such documentation leaves a visit suspect.  

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