Wound care documentation crucial for internists

Key takeaways:

• There has been litigation growth around wound care.
• Physicians should thoroughly examine and document wound presentations and suspect infection.

SAN DIEGO — Internists should prioritize the assessment, documentation and treatment of wounds, according to a speaker.

“Skin is an organ, and it fails just like other organs,” Jeffrey M. Levine, MD, said at the ACP Internal Medicine Meeting.

There is a growing medicolegal liability related to wounds, said Levine, who is a wound care and geriatrics specialist at the Icahn School of Medicine at Mount Sinai. Medicare spends up to $30 billion on wounds, he said.

When he asked if the audience had been trained to diagnose and treat wounds in medical school, only one person raised their hand.

“The lawyers know this. And they know this is a soft spot,” he said. There is litigation growth in the areas of chronic wounds, pressure wounds and other types of wounds.

Levine suggested that after examining the wound, the internist should indicate its etiology.

Also, if it is a pressure injury, the provider should stage it.

“If you can’t stage it, give me a couple of lines that describe it,” he said.

Physicians should also record the length (head to toe), with depth in centimeters (not inches), and note whether there is slough, necrosis or drainage and the type of drainage (serous, sanguineous, serosanguinous or purulent), he said.

When photographing the wound, include a patient identifier, the location of the wound and the date.

“If this was an unavoidable wound from skin failure, you need to put the rationale for why you think the skin has failed,” Levine said.

Levine also recommended using the local wound clinic if the patient’s wound is beyond the physician’s abilities to treat.

“When you examine someone with darker skin, you may miss it,” he said. “Make sure the lighting is adequate and the visual examination should be supplemented by taking your gloved hand and palpitating the area, feeling for warmth, induration or other things that may indicate inflammation or subcutaneous damage.”

Finally, providers should suspect infection, and if there is one, “treat it early and aggressively,” Levine said.