The Impact of Consistent and Accurate Wound Care Documentation on Home Health Care Outcomes and Appropriate Reimbursement

Wound care continues to be among the most prevalent and costly services provided by home healthcare agencies. Consistent and accurate documentation of wound care is essential in demonstrating patient progress and in receiving appropriate reimbursement from insurance companies. The framework for this study is based on Patricia Benner’s Novice to Expert Model. The purpose of this study is to examine the consistency of current wound care documentation practices by a small home healthcare agency in western Michigan. Using retrospective chart review, this descriptive, longitudinal study examines the consistency of specific aspects of wound care, including consistent photographs, measurements, and appropriate naming of the wounds. The sample included 14 clients with surgically dehisced wounds receiving in home wound care, and the data was analyzed using PASW 17.0. The results of the study found that wound care documentation was most consistent in the categories of measurements and photographs being taken. The findings of this study reinforce the importance and value of consistent wound care documentation. Limitations of the study include a small sample size and a narrow focus, including only clients with surgical wound dehiscence. Consistent documentation among home health nurses is critical to ensure optimal patient outcomes and to receive necessary reimbursement for the services provided