Wound Care Documentation Guide 2026
Master comprehensive wound assessment and documentation. Complete guide covering wound measurement, pressure injury staging, assessment templates, PUSH tool, photography guidelines, and billing codes.
Essential for nurses, wound care specialists, physicians, and all clinicians managing acute and chronic wounds.
Wound Care Documentation by the Numbers
Comprehensive Wound Assessment Components
Every wound assessment should include these six essential categories for complete documentation.
Wound Location & Size
- Anatomical location (specific and precise)
- Laterality (right/left)
- Distance from anatomical landmarks
- Length (longest dimension in cm)
- Width (perpendicular to length in cm)
- Depth (deepest point in cm)
- Undermining (location by clock position, depth)
- Tunneling/sinus tracts (clock position, depth)
Tip: Always measure in same orientation. Use clock face with 12:00 toward head for consistency.
Wound Edges & Margins
- Attached vs. unattached
- Rolled/epibole edges
- Macerated margins
- Undermining vs. tunneling
- Edge color and texture
- Epithelialization present
- Callused/hyperkeratotic edges
Tip: Rolled edges and undermining indicate poor healing potential and need for debridement.
Wound Bed Tissue Type
- Granulation tissue (red, beefy)
- Epithelial tissue (pink, from edges)
- Slough (yellow, stringy or thick)
- Eschar (black, hard or soft)
- Necrotic tissue (devitalized)
- Exposed structures (bone, tendon, muscle)
- Percentage of each tissue type
Tip: Document percentage of each tissue type. Granulation = healing, slough/eschar = needs debridement.
Exudate Characteristics
- Amount (none, scant, moderate, copious)
- Color (clear, serous, serosanguinous, purulent)
- Consistency (thin, thick, viscous)
- Odor (none, foul, offensive)
- Frequency of dressing changes needed
- Drainage saturation of dressing
Tip: Increased purulent drainage or foul odor suggests infection. Document dressing saturation percentage.
Periwound Skin
- Color (normal, erythema, cyanotic, purple)
- Temperature (warm, cool, hot)
- Edema/swelling (pitting vs non-pitting)
- Maceration (white, waterlogged)
- Induration (firmness, fibrosis)
- Pain level (0-10 scale)
- Intact vs. denuded/excoriated
Tip: Periwound erythema >2cm suggests infection. Maceration indicates excessive moisture.
Signs of Infection
- Increasing pain
- Erythema extending beyond wound
- Warmth/heat
- Purulent drainage
- Foul odor
- Delayed healing or wound breakdown
- Fever/systemic signs
- Cellulitis
Tip: Document signs/symptoms of infection explicitly. May warrant culture and antibiotics.
Pressure Injury Staging System (NPUAP/EPUAP)
Accurate staging is critical for treatment planning, reimbursement, and quality metrics. Never reverse-stage healing wounds.
Stage 1
Non-blanchable erythema of intact skin
Intact skin with localized area of non-blanchable erythema. May appear differently in darkly pigmented skin. Area may be painful, firm, soft, warmer or cooler compared to adjacent tissue.
Assessment Criteria
- •Press firmly - does NOT blanch white
- •Skin is intact (no break)
- •Area may be painful to touch
- •May feel different temperature than surrounding skin
- •In dark skin: purple, maroon, or color different from surrounding area
Intervention Focus
Pressure relief, repositioning, support surfaces, skin protection
Stage 2
Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. Wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister. Does NOT include skin tears, tape burns, or moisture-associated skin damage.
Assessment Criteria
- •Dermis visible (pink/red)
- •Partial thickness - does NOT expose fat
- •May be shallow open ulcer
- •May present as intact or open blister
- •Moist wound bed
- •No slough or eschar
Intervention Focus
Moist wound healing, appropriate dressings, continued pressure relief
Stage 3
Full-thickness skin loss
Full-thickness loss of skin in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Depth varies by anatomical location. Undermining and tunneling may occur.
Assessment Criteria
- •Full thickness - fat is visible
- •Granulation tissue present
- •Slough or eschar may be present
- •Depth varies by location
- •Undermining/tunneling possible
- •Bone, tendon, muscle NOT exposed
Intervention Focus
Debridement if indicated, moist wound care, pressure relief, nutritional support
Stage 4
Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location.
Assessment Criteria
- •Full thickness tissue loss
- •Exposed bone, tendon, muscle, fascia
- •Often very deep
- •Slough/eschar common
- •Undermining/tunneling common
- •High risk for osteomyelitis if bone exposed
Intervention Focus
Surgical consultation often needed, aggressive debridement, advanced wound care, pressure relief
Unstageable
Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.
Assessment Criteria
- •Wound bed obscured by slough (yellow, tan, gray)
- •Wound bed obscured by eschar (tan, brown, black)
- •Cannot determine true depth
- •May be full thickness
- •Do NOT remove stable eschar on heels
Intervention Focus
Debridement to determine stage (except stable heel eschar), moisture balance
Deep Tissue Pressure Injury (DTPI)
Persistent non-blanchable deep red, maroon or purple discoloration
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes.
Assessment Criteria
- •Skin may be intact or have blood-filled blister
- •Deep red, purple, or maroon color
- •Does NOT blanch
- •May be painful
- •Area may feel boggy or firm
- •May evolve rapidly to Stage 3 or 4
Intervention Focus
Aggressive pressure relief, close monitoring (may deteriorate rapidly), nutritional support
Critical Staging Reminders
- • Never reverse-stage a healing pressure injury (Stage 3 does NOT become Stage 2)
- • Cannot stage through eschar - must debride or label as Unstageable
- • Medical device-related pressure injuries are staged using same system
- • Mucosal membrane pressure injuries cannot be staged (use "mucosal membrane pressure injury")
- • Document stage at initial assessment; for healing wounds document as "healing Stage X"
Common Wound Types & Classification
Different wound etiologies require specific assessment and documentation approaches.
Pressure Injury
Etiology: Sustained pressure exceeding capillary closing pressure (32 mmHg)
Common Locations:
Key Characteristics:
- •Often over bony prominence
- •Regular, defined borders
- •May have undermining
- •Depth can exceed surface appearance
Documentation Focus:
Use NPUAP staging system, Braden scale for risk assessment, document pressure relief measures
Diabetic Foot Ulcer
Etiology: Neuropathy, peripheral arterial disease, repetitive trauma
Common Locations:
Key Characteristics:
- •Often on weight-bearing areas
- •Punched-out appearance
- •Callused edges
- •May have minimal pain (neuropathy)
- •Granular base or exposed structures
Documentation Focus:
Wagner grade, probe to bone test, monofilament test results, vascular assessment (ABI, pulses)
Venous Stasis Ulcer
Etiology: Chronic venous insufficiency, valve incompetence
Common Locations:
Key Characteristics:
- •Irregular, shallow borders
- •Moderate to heavy exudate
- •Red, beefy granulation tissue
- •Hemosiderin staining (brown)
- •Surrounding edema
- •Lipodermatosclerosis
Documentation Focus:
Document edema, skin changes, compression therapy used, ABI to rule out arterial disease
Arterial Ulcer
Etiology: Peripheral arterial disease, ischemia
Common Locations:
Key Characteristics:
- •Well-defined borders (punched out)
- •Pale or necrotic wound bed
- •Minimal exudate
- •Severe pain (especially at night)
- •Cool, hairless skin
- •Diminished or absent pulses
Documentation Focus:
Vascular assessment mandatory (ABI, pulses, Doppler), refer vascular surgery if ABI <0.9
Surgical Wound
Etiology: Incision from surgical procedure
Common Locations:
Key Characteristics:
- •Linear incision
- •May be approximated or open
- •Sutures, staples, or steri-strips
- •Expected healing by primary, secondary, or tertiary intention
Documentation Focus:
Healing by intention (primary/secondary/tertiary), suture type, removal date, signs of dehiscence
Skin Tear
Etiology: Shearing forces, fragile skin
Common Locations:
Key Characteristics:
- •Irregular shape (flap present or absent)
- •Linear or irregular tear
- •Skin flap may be viable or non-viable
- •Common in elderly
Documentation Focus:
ISTAP classification, flap viability, approximate if possible
Wound Measurement Techniques
Accurate, consistent measurement is essential for tracking healing progress and clinical decision-making.
Linear Measurement (Length x Width x Depth)
Good for regular wounds; less accurate for irregular shapesStandard wound measurement using ruler
Procedure:
- 1.Use same orientation each time (clock method: 12:00 toward head)
- 2.Length: Measure longest dimension (head to toe direction)
- 3.Width: Measure widest dimension perpendicular to length
- 4.Depth: Insert cotton-tip applicator at deepest point, mark, measure against ruler
- 5.Document undermining: Probe gently, measure depth, note clock position
- 6.Document tunneling: Measure depth and note clock position
Documentation Example:
Example: 4.5cm (L) x 3.2cm (W) x 1.8cm (D), undermining 2cm at 3:00
Wound Tracing
Excellent for surface area; does not capture depthTrace wound perimeter on transparency film
Procedure:
- 1.Place sterile transparency film over wound
- 2.Trace wound edges with sterile marker
- 3.Transfer to paper grid or scan for digital measurement
- 4.Calculate surface area using grid or planimetry software
- 5.Keep tracing in medical record for comparison
Documentation Example:
Surface area: 14.3 cm². Include tracing in chart or photograph
Digital Photography
Excellent for visual progress tracking; can measure if ruler includedStandardized wound photography for documentation
Procedure:
- 1.Position same distance from wound each time (6-12 inches ideal)
- 2.Include ruler or measurement guide in frame
- 3.Ensure adequate lighting (avoid shadows)
- 4.Position camera perpendicular to wound bed
- 5.Take multiple angles if needed
- 6.Document in photo: patient ID, date, wound location
- 7.Obtain consent for photography
Documentation Example:
Photo includes date, location, ruler. Stored in EHR with HIPAA compliance
3D Wound Imaging
Excellent - most accurate method availableAdvanced imaging technology for volume calculation
Procedure:
- 1.Use specialized device (ARANZ, Swift, etc.)
- 2.Position device over wound per manufacturer guidelines
- 3.Device calculates length, width, depth, area, and volume
- 4.Highly accurate and reproducible
- 5.Data stored digitally for trend analysis
Documentation Example:
Device-generated report with precise measurements and volume calculation
PUSH Tool - Pressure Ulcer Scale for Healing
Validated tool to objectively monitor pressure injury healing trajectory over time.
PUSH Tool (Pressure Ulcer Scale for Healing)
Validated tool to monitor pressure injury healing over time
Length x Width
0-10 points0 = 0 cm², 1 = <0.3 cm², 2 = 0.3-0.6 cm², 3 = 0.7-1.0 cm², 4 = 1.1-2.0 cm², 5 = 2.1-3.0 cm², 6 = 3.1-4.0 cm², 7 = 4.1-8.0 cm², 8 = 8.1-12.0 cm², 9 = 12.1-24.0 cm², 10 = >24 cm²
Exudate Amount
0-3 points0 = None, 1 = Light, 2 = Moderate, 3 = Heavy
Tissue Type
0-4 points0 = Closed, 1 = Epithelial tissue, 2 = Granulation tissue, 3 = Slough, 4 = Necrotic tissue
Scoring & Interpretation
Total Score Range: 0-17 (higher = worse)
Interpretation: Decreasing score = healing. Increasing score = deterioration. Track weekly.
Example: PUSH score 12 (Size: 7, Exudate: 2, Tissue: 3). Down from 14 last week.
Wound Photography Guidelines
Standardized photography is essential for visual documentation and tracking healing progress.
Consent & Privacy
- Obtain written consent for wound photography
- Explain purpose and use of photos
- Ensure photos are HIPAA-compliant and secure
- Do not include patient identifiers visible in photo (face, tattoos)
- Document consent in medical record
Technical Standards
- Use adequate lighting (natural or supplemental)
- Position camera perpendicular to wound (90-degree angle)
- Distance: 6-12 inches from wound typically
- Include measurement tool in frame (ruler)
- Focus clearly on wound bed and periwound
- Take multiple angles if needed
Documentation Elements
- Date and time visible (in frame or metadata)
- Patient identifier (on label, not on patient)
- Wound location labeled
- Sequential numbering if multiple wounds
- Consistent orientation (12:00 toward head)
- Include comparison photos from previous visits
Storage & Security
- Store in encrypted, HIPAA-compliant system
- Link photos to patient EHR
- Ensure backup and retention per facility policy
- Limit access to authorized personnel only
- Include in wound care flow sheet
Photography Best Practices Summary
- • Obtain consent
- • Clean wound
- • Prepare equipment
- • Include ruler in frame
- • Perpendicular angle
- • Adequate lighting
- • Label immediately
- • Store securely (HIPAA)
- • Link to EHR
Treatment & Intervention Documentation
Document treatments thoroughly including products used, technique, and patient response.
Dressing Changes
Required Documentation Elements:
- Dressing type (foam, hydrocolloid, alginate, etc.)
- Primary and secondary dressings used
- Frequency of changes
- Wound cleansing solution used
- Patient tolerance of procedure
- Education provided to patient/caregiver
Documentation Example:
Wound cleansed with normal saline. Hydrocolloid dressing applied, intact edges. Change in 3 days or prn for saturation. Patient tolerated well, educated on signs of infection.
Debridement
Required Documentation Elements:
- Type: sharp, enzymatic, autolytic, mechanical, surgical
- Amount of tissue removed
- Tissue removed from which area (clock position)
- Bleeding (none, minimal, moderate)
- Pain management provided
- Wound appearance post-debridement
- Specimen sent for culture/pathology if applicable
Documentation Example:
Sharp debridement performed at bedside. Slough debrided from 12:00-6:00 region, approximately 2cm x 1cm area. Minimal bleeding, controlled with pressure. Lidocaine 1% applied topically for pain. Wound bed now 90% granulation, 10% slough remaining. Patient tolerated well.
Negative Pressure Wound Therapy (NPWT)
Required Documentation Elements:
- Device type and settings (-125mmHg continuous, etc.)
- Foam type (black, white) and size
- Seal integrity
- Dressing change frequency
- Wound measurements with NPWT removed
- Granulation tissue response
- Plan for continued NPWT or transition
Documentation Example:
VAC dressing changed. Black foam, 10cm x 8cm, applied to wound bed. -125mmHg continuous therapy initiated. Good seal achieved. Wound granulation improved from 60% to 80% since last change. Continue NPWT with changes every 3 days. Patient educated on alarm response.
Offloading/Pressure Relief
Required Documentation Elements:
- Specific device (air mattress, heel protectors, cushions)
- Repositioning schedule (every 2 hours)
- Compliance with offloading
- Total contact cast, walking boot, wheelchair cushion
- Patient/caregiver education on importance
Documentation Example:
Patient on low air loss mattress. Repositioning every 2 hours, documented on turn log. Heels elevated on pillows, free-floating. Pressure mapping shows effective offloading of sacrum. Patient/family educated on importance of continued repositioning.
Infection Management
Required Documentation Elements:
- Wound culture obtained (type: swab, tissue)
- Clinical signs of infection present
- Antibiotics initiated (systemic or topical)
- Response to antimicrobial therapy
- Culture results and sensitivities
Documentation Example:
Wound culture obtained via tissue biopsy due to signs of infection (increased erythema 3cm periwound, purulent drainage, foul odor). Empiric antibiotics started: Vancomycin 1g IV q12h pending cultures. Will follow-up culture results in 48 hours. Surgical debridement scheduled.
Wound Care CPT Codes & Billing
Common billing codes for wound care services. Documentation must support medical necessity.
Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
Documentation Requirements: Document surface area debrided, method, tissue type removed, post-debridement appearance
Debridement, each additional 20 sq cm or part thereof (add-on code)
Documentation Requirements: Use with 97597 for larger wound debridement. Calculate total surface area.
Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session
Documentation Requirements: Non-selective methods: wet-to-dry, enzymatic. Document method and wound response.
Negative pressure wound therapy (NPWT), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
Documentation Requirements: Document NPWT settings, foam type, seal, wound measurements, clinical response
NPWT, total wound(s) surface area greater than 50 square centimeters
Documentation Requirements: Calculate total surface area if multiple wounds under NPWT
Debridement, subcutaneous tissue (11042), muscle/fascia (11043), bone (11044), with add-on codes for each additional 20 sq cm
Documentation Requirements: Use for surgical/extensive debridement. Document depth and structures debrided.
Application of skin substitute graft to trunk, arms, legs; first 100 sq cm or less, each additional 100 sq cm
Documentation Requirements: Document product name, size applied, indication, wound preparation
Billing Documentation Tips
- • Calculate and document total surface area for debridement codes
- • Time-based codes require start/end time documentation
- • Medical necessity must be clearly documented (infection, delayed healing, etc.)
- • Include ICD-10 codes for wound type and location
- • Document complexity factors that support code selection
Complete Wound Care Documentation Example
Comprehensive wound note demonstrating all required documentation elements.
Pressure injury
78-year-old female, nursing home resident, limited mobility
WOUND ASSESSMENT - Right Heel Pressure Injury Location: Right heel, posterior surface, slightly lateral Stage: Stage 3 pressure injury (full thickness, adipose visible) Measurements: - Length: 3.2 cm (12:00-6:00) - Width: 2.8 cm (3:00-9:00) - Depth: 1.4 cm (deepest at center) - Undermining: 0.5 cm at 9:00-12:00 - No tunneling - Surface area: 8.96 cm² (calculated) Wound Bed: - 70% red granulation tissue (healthy, beefy) - 30% yellow slough (loose, stringy) - No eschar, no exposed bone/tendon - No odor Wound Edges: - Well-defined borders - Edges slightly rolled at 3:00 position - No maceration - Epithelial tissue visible at 6:00 margin (0.5cm) Exudate: - Moderate amount - Serosanguinous (pink-tinged, clear) - No purulent drainage - No foul odor - Dressing saturated approximately 50% at change Periwound Skin (2cm circumference): - Erythema extending 1cm from wound edge, blanches with pressure - Skin intact, no maceration - Warm to touch (normal, not hot) - No induration - No edema Pain: 4/10 with dressing change, 1/10 at rest Signs of Infection: None identified - No cellulitis - No purulent drainage - Erythema localized and blanches - Temperature normal - No systemic signs Previous Assessment (7 days ago): - Size: 3.8cm x 3.2cm x 1.6cm - Showing improvement in size and depth - Granulation increased from 60% to 70% PUSH Score: 10 (Size: 6, Exudate: 2, Tissue: 2) - improved from 11 Treatment: - Wound cleansed with normal saline - Sharp debridement of 30% loose slough performed with scissors and forceps - Small amount of bleeding, controlled with gauze pressure - Calcium alginate dressing applied to wound bed - Foam secondary dressing applied - Change every 3 days or PRN for saturation - Heel offloading boot in place, worn continuously except during wound care - Air mattress in use - Patient repositioned every 2 hours per protocol Nutritional Support: - High-protein supplement twice daily - Albumin 3.2 (drawn today, improved from 2.9) - Dietitian consulted, recommendations implemented Patient Education: - Family present, educated on importance of offloading - Reviewed signs of infection to report - Heel boot demonstration provided Plan: - Continue current dressing regimen - Continue pressure relief measures (boot, air mattress, repositioning) - Reassess in 1 week - Consider NPWT if healing plateau occurs - Monitor for signs of infection - Continue nutritional support Assessment: Right heel Stage 3 pressure injury showing appropriate healing trajectory. Size, depth, and slough decreasing. Granulation tissue improving. Continue current treatment plan. Next assessment: [Date, 1 week] Practitioner signature: [Name, credentials, date/time]
Common Wound Documentation Mistakes
Avoid these frequent errors that compromise care quality and reimbursement.
Vague wound location
Problem: Documenting "sacral wound" without precise location
Solution: Be specific: "Sacral pressure injury, midline, 3cm superior to coccyx"
Inconsistent measurement orientation
Problem: Measuring length different direction each time, preventing accurate comparison
Solution: Always use clock method with 12:00 toward head. Document orientation used.
Not staging pressure injuries correctly
Problem: Staging based on appearance rather than depth/tissue involved
Solution: Follow NPUAP staging definitions precisely. Unstageable if slough/eschar obscures depth.
Forgetting to document periwound
Problem: Only documenting wound bed, missing critical periwound assessment
Solution: Always assess and document periwound skin: color, temperature, edema, maceration, induration.
Not quantifying exudate
Problem: Writing "draining" without amount or character
Solution: Document amount (scant/moderate/copious), color, consistency, odor. Note dressing saturation.
Missing infection signs
Problem: Not documenting clinical signs that warrant intervention
Solution: Explicitly assess and document: pain, erythema extent, warmth, purulent drainage, odor, delayed healing.
No treatment response documentation
Problem: Changing treatment without documenting why
Solution: Document wound response to current treatment. If changing, explain rationale.
Inadequate photography
Problem: Photos without ruler, poor lighting, inconsistent angle
Solution: Standardize technique: include ruler, perpendicular angle, consistent distance, adequate light.
Automate Wound Care Documentation with AI
PatientNotes AI captures your verbal wound assessments and generates comprehensive documentation including all required elements: measurements, tissue type, staging, exudate, periwound, and treatment.
Frequently Asked Questions
Common questions about wound care documentation answered.
What are the essential components of wound care documentation?
Essential components include: precise anatomical location, measurements (length, width, depth), wound bed tissue type percentages, exudate amount/character/color, periwound skin assessment, edges/margins, undermining/tunneling, pain level, signs of infection, treatment provided, and wound response to treatment. For pressure injuries, include staging and PUSH score.
How do I correctly measure a wound?
Use the clock method with 12:00 toward the patient's head for consistency. Measure length (longest dimension, typically head-to-toe), width (perpendicular to length at widest point), and depth (cotton-tip applicator at deepest point, mark and measure against ruler). For undermining, gently probe edges and note clock position and depth. Document in cm. Always measure in same orientation for accurate comparison.
What is the difference between pressure injury stages?
Stage 1: Intact skin, non-blanchable redness. Stage 2: Partial thickness, dermis exposed, may be blister. Stage 3: Full thickness, fat visible, no bone/tendon. Stage 4: Full thickness with exposed bone, tendon, or muscle. Unstageable: Full thickness but depth obscured by slough/eschar. Deep Tissue Injury: Purple/maroon intact or non-intact skin, may evolve rapidly. Do not reverse-stage as wounds heal.
When should I suspect a wound infection?
Suspect infection with: increasing pain, erythema extending >2cm from wound edge, warmth/heat, purulent drainage (thick, opaque, yellow/green), foul odor, delayed healing or wound deterioration, increased exudate, friable granulation tissue that bleeds easily, or systemic signs (fever, elevated WBC). Document all signs explicitly and consider wound culture (tissue biopsy preferred over swab).
What is the PUSH tool and when should I use it?
The Pressure Ulcer Scale for Healing (PUSH) tool is a validated instrument to track pressure injury healing over time. It scores three parameters: wound size (0-10), exudate amount (0-3), and tissue type (0-4) for a total score of 0-17. Higher scores indicate worse wounds. Use it weekly to objectively track healing trajectory. Decreasing scores indicate healing; increasing scores suggest deterioration requiring intervention.
How often should wound documentation be completed?
Frequency depends on wound severity and setting. Acute care: daily for complex wounds. Long-term care: weekly for pressure injuries per CMS regulations. Home health: at each visit (typically weekly). Outpatient: at each appointment. More frequent documentation is needed for infected wounds, deteriorating wounds, or wounds requiring daily dressing changes. Always document after significant changes in treatment.
What are the billing codes for wound care?
Common codes include: 97597/97598 (selective debridement), 97602 (non-selective debridement), 97605/97606 (NPWT), 11042-11047 (surgical debridement by depth), and 15271-15278 (skin substitute application). Documentation must support medical necessity, include surface area, method used, and clinical response. Always document time, complexity, and specific interventions performed.
Can AI help with wound care documentation?
Yes, AI documentation tools like PatientNotes can streamline wound care charting by capturing verbal assessments during wound care procedures, ensuring all required elements are documented (location, measurements, tissue type, exudate, periwound), and generating comprehensive notes. This reduces documentation time while maintaining thoroughness and consistency, especially valuable when managing multiple wounds or complex wound care regimens.
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