APMA News - January/February 2024 - 24

Best Practices for Wound
Documentation
By Jeffrey Petty, DPM, and Andrew Pavelescu, DPM
Accurate and thorough documentation of lower
extremity wounds is of paramount importance in
the progress note. Proper documentation serves
several critical purposes, including providing a detailed
clinical history, tracking the progression of a
wound, facilitating communication with other providers,
coding, audit defense, and supporting any
legal process. In this article, we will discuss some
essential elements of documenting wounds to
ensure comprehensive and effective patient care.
When documenting a wound care episode, one
must keep in mind two important rules:
1. If it wasn't documented, it wasn't done.
2. Each encounter must be able to stand on its own.
It is incumbent upon the clinician to establish
the medical necessity of services provided, document
the details of the treatment provided, and
24
apmanews
JANUARY/FEBRUARY 2024
document the plan of care with each episode of
care. The mere presence of a diagnosis does not
constitute medical necessity. Therefore, there must
be a specific reasonable and medically necessary
purpose for each service. The documentation for
each encounter should include:
* Chief Complaint (CC)- A brief description of
the reason the patient sought medical attention.
This need for each visit should be in the
patient's words and not doctor/medical assistant
language.
* History of Present Illness (HPI)- Obtaining an
accurate and detailed history is crucial in the
documentation of patients with wounds.
* Physical Exam Findings (PE)- When documenting
a wound, the patient's medical record must
contain clearly documented evidence of the

APMA News - January/February 2024

Table of Contents for the Digital Edition of APMA News - January/February 2024

Contents
APMA News - January/February 2024 - Cover1
APMA News - January/February 2024 - Cover2
APMA News - January/February 2024 - 3
APMA News - January/February 2024 - 4
APMA News - January/February 2024 - 5
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APMA News - January/February 2024 - Contents
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APMA News - January/February 2024 - Cover3
APMA News - January/February 2024 - Cover4
APMA News - January/February 2024 - A1
APMA News - January/February 2024 - A2
APMA News - January/February 2024 - A3
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