We aim to formulate optimal documentation to demonstrate wound care that upholds guidelines set forth by Centers for Medicare & Medicaid Services (CMS). We document extensive wound care characteristics for both pressure injuries and non-pressure ulcer/injury wounds including the following:
- Status of the wound healing
- Status of pre-existing/present on admission
- Effectiveness of current wound care
- Rationale of wound care modification
We document our wound care evaluation and management in the medical record system of the facility which enables the staff to have quick access to our records. We are well versed in many electronic medical record (EMR) applications including the following: Swift Medical, PointClickCare, Epic, and i-heal. We use dragon and a transcription service to enable prompt completion and access of our records in a day (within 24 hours).
Our partnership with Swift Medical, an electronic medical record (EMR) provider for wound care, entails image documentation of the wounds to be stored in medical records. This enables enhanced tracking of the wound healing and the effectiveness of the treatment. The images are available online in their website and can be easily downloaded in nursing facilities EMR including PointClickCare.