APMA News - January/February 2024 - 25

progress of the wound's response to treatment
at each visit. This documentation must include,
at a minimum:
* Location-Be as specific as possible regarding
the exact anatomic location of each ulceration.
* Stage-Describe the stage of the ulceration, if
appropriate. Keep in mind that different ulcer
types have different staging systems.
* Size-Length x width x depth in centimeters.
Both pre- and post-debridement measurements
may be included in the progress note.
It is also a good idea to include the initial measurements
of the wound from when treatment
was first initiated or make reference to the
date and the percentage of improvement.
* Depth-Be sure to include any tunneling or
undermining.
* Infection-Presence or absence of signs of
infection.
* Wound bed-Color, texture, presence or
absence of granulation tissue, necrotic and/or
non-viable tissue, and fibrotic tissue. The documentation
needs to be specific about which
tissue is involved.
* Drainage-Document the presence or absence
of drainage. If present, document the
type, amount, and any odor.
* Wound edges-Advancing, undermining, tunneling,
rolling, hyperkeratotic, atrophic.
* Photographs-Taking pre- and post-debridement
photos can be valuable.
* Assessment- This statement is today's clinical
impression, or diagnosis.
* Medical plan of care-This documentation
should include what decisions were made
as a result of this encounter. Did you discuss
offloading and/or different shoe gear? Were
any referrals necessary to help assist in wound
healing such as: primary care physician, nurse
practitioner, endocrinologist, vascular specialist,
cardiologist, and/or infectious disease specialist?
Some goals of wound debridement are to
remove devitalized tissue, decrease the risk of
infection, promote wound healing, prevent further
complications, and/or prepare the tissue for surgical
management. When documenting the need for
debridement services, it is important to detail these
goals as well as the following information:
* Type of tissue removed during the procedure-
Skin, full or partial thickness; subcutaneous
tissue; muscle/fascia and/or bone.
* Method used to debride-Hydrosurgical, sharp, etc.
* Description of instrumentation used-Scalpel,
curette, tissue nipper, etc.
* Character of the wound-Did it bleed easily or
minimally; does it appear to be able to improve
without other specialty intervention, etc.?
* Measurable changes-Increase or decrease of
drainage, inflammation, swelling, pain, wound
dimensions, and necrotic or non-viable tissue/
slough.
* Dressings applied to each ulcer
After debridement is performed, there must be a
treatment plan. Like any other service, you need to
outline specific goals, duration, frequency, modalities,
an anticipated endpoint, patient/caregiver
instructions and involvement, and other pertinent
factors as they may apply. Departure from the
established treatment plan must be documented. It
is expected that a wound care treatment plan will
be modified in the event that appropriate healing
is not achieved in a reasonable amount of time,
which is typically 30 days.
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APMA News - January/February 2024

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