Jeanne R Lowe1, Gregory J Raugi, Gayle E Reiber, Joanne D Whitney. 1. Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Manager, UW Medicine Pay for Performance, Seattle, WA 98104, USA. jlowe@u.washington.edu
Abstract
PURPOSE: The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention. METHODS: From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding. RESULTS: The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001). CONCLUSIONS: An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.
PURPOSE: The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention. METHODS: From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding. RESULTS: The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001). CONCLUSIONS: An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.
Authors: Jennifer A Mayfield; Gayle E Reiber; Lee J Sanders; Dennis Janisse; Leonard M Pogach Journal: Diabetes Care Date: 2004-01 Impact factor: 19.112
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