Documentation Guidelines in Skin Ulcers

According to the Columbia University Medical Center's Department of Surgery, pressure ulcers are caused when there is a physical breakdown of the skin layers resulting from continuous pressure at certain points on the body. This breakdown is a result of a decrease in blood flow and circulation caused by the pressure on the affected area. Though they can technically occur anywhere on the body, some areas are more common, such as the sacrum, the area just above the buttocks, feet and calves. Because the skin and often muscle break down, a very painful sore develops.

The importance of documentation

CMS (Center for Medicaid and Medicare Services) will not reimburse health care organizations for conditions that occurred during a hospital stay, such as infections and pressure ulcers. The cost of treating a pressure ulcer can vary from a few hundred dollars to well into the thousands. For hospitals to eat that cost can mean a potentially significant drop in monies coming in. That is why documentation of the ulcers is key. If done correctly, it can potentially save the hospitals thousands of dollars in lost revenue.

The first step: Identifying risk

Staff should begin their documentation process by performing a thorough skin assessment on the patient upon arrival. According to the Institute for Clinical System Improvement, staff should use the following to evaluate patients' skin conditions: if the patient is bed-bound or confined to a wheelchair, will they be immobile (including sedated) for greater than two hours; does the patient have a history of pressure ulcers; if the patient is under 5 years or over 65; is the patient malnourished; and what their vascular and blood flow conditions are at the time.

Special attention and documentation should be made when the patient has any kind of vascular disease, heart attack history, stroke history, fractures, internal bleeding, trauma to the spinal cord, neurological disorders, diabetes, kidney disease, cancer or congestive heart failure to name a few (www.icsi.org).

According to ICSI, patients 75 years of age or greater and/or patients with multiple high-risk diagnoses should be advanced to the next level of risk, as should surgical patients.

Once risks have been identified

A patient's risks for pressure ulcers should be made an official part of the patient's legal medical record. Any and all sites of potential stage 1 or 2 pressure ulcers must be documented if present. CMS will reimburse the hospital if the pressure ulcers were documented on admission, even if they get worse throughout their stay. Staff must also document if a patient refuses the skin assessment.

Continual assesments

Skin assessments and inspections should not be concluded after the initial inspection. Once or twice daily inspections should be made throughout the patient's hospital stay and those evaluations should be clearly documented with date and time completed. Preventative steps should be taken with high-risk patients, such as increasing their mobility if possible, or if patient is immobile, rotating them frequently.

For patients undergoing surgical procedures, care and attention should be made during the procedure when at all possible. Patients can develop skin breakdowns while sedated during long procedures. It would be a good idea to have an operating room staff member inspect high-risk areas throughout the procedure. Documentation that this has been completed is key.

Considerations

Pressure ulcer prevention and documentation is more than just a reimbursement issue. Patient satisfaction and quality of care is the primary focus of hospitals. To improve quality and patient safety, CMS took drastic measures by denying reimbursements for hospital-acquired conditions. Pressure ulcers are extremely painful and harmful, even potentially life-threatening if an infection develops.

Pressure ulcers are one of 11 non-reimbursable conditions, according to CMS. To make sure the hospital is able to obtain the highest reimbursement rate, prevention and documentation are must-haves. Without documentation, the hospital will have no hopes of recouping expenditures resulting from pressure ulcer treatments.