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Documentation: HBO Consultation History and Physical

Documentation: HBO Consultation History and Physical

Documentation: HBO Consultation History and Physical

INTRODUCTION

Evaluation and Management 

Clear and concise medical record documentation is critical to providing patients with quality care and is required for you to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation helps physicians and other health care professionals evaluate and plan the patient’s immediate treatment and monitor the patient’s health care over time. [1]

The following consultation template will assist providers with initial documentation requirements for Hyperbaric oxygen therapy. This template is for reference only and all data contained within is purely hypothetical. 

DOCUMENTATION FOR HYPERBARIC OXYGEN THERAPY

Consultation Template for HBOT

  • Patient Name
  • Medical Record/Transaction Number
  • DOB
  • Referring Physician Name
  • PCP Name
  • Consultation Date
  • Dictation Date
  • Type of Consultation: Wound Care, Wound Care + Hyperbaric Oxygen, Hyperbaric Oxygen
  • Reason for Consultation

History of Present Illness

The patient is a ___ y/o ____ with a history of ____

The patient has been referred to ______________________  Chronic Wound Care and Hyperbaric Medicine Clinic for consultation and further evaluation of his/her wounds. We will also offer recommendations for care.

Past medical history/ Past surgical history (PMH/PSH):

as applicable

Medications:

as applicable

Allergies:

as applicable

Social History:

Living situation (alone, family, assisted living, retirement home, etc), marital status, children, ETOH, tobacco, illicit drug use, etc.

Family History:

as applicable

Review of Systems:

  • General: Fever, chills, night sweats. Unintentional weight gain/weight loss
  • HEENT: Glasses (near vision, far vision, etc.), cataracts, blurred vision, vision loss, eye pain, hearing loss, tinnitus, vertigo, sinusitis, congestion epistaxis, teeth/gum pain, dysphagia, can/cannot clear ears.
  • Pulmonary: Cough, cold, asthma, bronchitis, sputum production, SOB, wheezing, sleep apnea, oxygen use, history of spontaneous pneumothorax
  • Cardiac: Chest pain, pressure under sternum, palpitations, murmur, artificial valves, history of cardiac surgery, PND, DOE, LE edema
  • GI: abdominal pain, previous abdominal surgeries, N/V, D/C, GERD
  • GU: dysuria, urgency, frequency, nocturia, incontinence, hesitancy,
  • MS: Joint stiffness, arthritis, swelling, back pain
  • Endocrine: Diabetes mellitus, thyroid disorders, polyuria, polydipsia, polyphagia
  • Hematology/Oncology: History of cancer, chemotherapy, specifically address bleomycin, easy bruising, bleeding disorders, taking coumadin/heparin/thrombolytics, daily aspirin
  • Dermatology: Rash, itching, previous non-healing wounds/ulcers, previous skin breakdown, previous wound care products
  • Neuro: Headache, syncope, stroke, pre-stroke, mini-stroke, paresthesias, tremors, aphasia, confusion, dementia, Parkinsonism, etc.
  • Psych: Depression, anxiety, panic attacks, specifically address claustrophobia,
  • **The remainder of the patient's review of systems is otherwise unremarkable. There are no absolute or relative contraindications at this time for hyperbaric oxygen therapy, should it be necessary.**

    Review of the Medical Records:

    The patient’s medical records were obtained and reviewed.

    • Wound culture
    • Previous wound care
    • Radiation doses and port areas 
    •  Etc.

      Physical Examination:

      • Appears stated age, alert, oriented x___, well developed, well nourished.
      • VS: BP, HR, RR, Temp, Pulse Ox, Ht, Wgt
      • HEENT:
        •  H: Normocephalic, atraumatic
        • E: PERRL, EOM intact
        • E: Bilateral canals without drainage, condition of TMs, 
        • Face: No evidence of trauma, hemorrhage, etc.
        • N: Nostrils without drainage
        • Mouth/Throat: Oral mucosa is pink and moist, tongue is well papillated, midline, coatings, dentition (caries, partial plates,         dentures), no suspicious lesions or ulcerations

      • Neck: Supple without lymphadenopathy. Trachea is midline. Carotid pulses, bruits
      • Respiratory: Lungs are CTA throughout bilaterally (wheezes, rhonchi, crackles, rales, rubs), no accessory muscle use
      • Cardiac: RRR, S1S2. Murmurs, rubs, gallops, JVD
      • Abdomen: Appearance (scaphoid, flat, obese, distended). Tender/Non-tender. Hepatosplenomegaly. BS
      • Genitalia: Describe as necessary for condition. Deferred.
      • Extremities: Skin (color, turgor, clubbing, cyanosis, temperature), peripheral pulses, capillary refill time, lesions, breakdown, edema, evidence of infection, etc.
      • Neuro: Alert, oriented, CN II-XII grossly intact

        Transcutaneous Oximetry:

        Transcutaneous oximetry was performed and the following values are recorded as a ratio of room air to 100% oxygen breathing. Oxygen is provided by tight-fitting, non-rebreathing mask, and the patient is placed in the supine position throughout. Comment on whether or not the patient requires oxygen as a baseline. The following sites were measured, including …. periwound areas.

        • Site #1 lead is placed _____ and used as a central reference lead.
        • Site #2 is located ____ with values of XX/XXX. … etc. 

        Summary: Transcutaneous oximetry at this evaluation point shows …

        • good tissue oxygenation in all of the measured locations. The patient had excellent tissue oxygen augmentation when breathing 100% oxygen by facemask. OR
        • This test indicates that the patient has marginal/poor/critical tissue oxygenation. Values less than 30mmHg when breathing room air and less than 100mmHg when breathing 100% oxygen indicate poor tissue perfusion and call into question the patient’s ability to heal a chronic wound/ulcer in that area. This generally suggests a limitation in arterial oxygen supply to the skin region(s) in question.
        • Comment on: The test could be artificially low due to the patient’s edema in the extremity of the lead placed too close to a bony prominence. We recommend that this patient have a thorough vascular workup on the extremity in question.

        Diagnosis: 

        • From a wound care standpoint,...
          • Code diabetes first
          • Code wound second
        • *** For all soft tissue radiation injury, code STRN and then anatomical location:
          • L59.8 Other disorder of the skin and subcutaneous tissue related to radiation (STRN) 
          • Anatomical location

          Impression/Plan:

          • Briefly summarize the HPI.
          • Local wound factors influencing wound healing include: 
            • Presence of foreign body(ies)
            • Depth of wound/ulcer
            • Tunneling/Undermining
            • Degree of chronicity
            • Wound location (especially perianal, perineal)
            • Evidence of infection; history of MRSA, CA-MRSA, or other virulent infections
          • Compromised wound healing can also be due to systemic factors, including …
            • Generalized edema
            • Alcoholism
            • Immunocompromised (Chronic steroid use, chemotherapy, hereditary, etc.)
            • Neutropenic
            • HIV positive
            • Chronic disease
            • Protein malnourishment
            • Radiation
            • Recent prior surgeries
            • Recent hospitalization/immobilization
          • We will begin wound care with a regiment of: 
            • Hydrogel - moist wound healing environment
            • Foam - absorbs exudates and prevents periwound maceration
            • Alginate - assists with exudates/draining/bioburden management
            • Panafil/Accuzyme/Collagenase - Gentle enzymatic debrider for necrotic tissue, fibrin, slough. Stimulates granulation tissue.
            • Iodosorb/Iodoflex - Cadexemer iodine formulation. Slow release iodine, acts as antiseptic and effective against bacteria such as MRSA, CA-MRSA, Pseudomonas, etc.
            • Bactroban - Helps decrease bacterial bioburden. Acts as a general antiseptic in the wound, with special activity against MRSA.
            • Silver cation - slow-release compound that is effective at killing antibiotic-resistant bacteria strains. 
            • Xenaderm – Provides a complete moisture barrier at the skin level, decreases skin irritation, and promotes epithelialization.
          • Frequency of dressing changes
          • Our goal is to provide a moist wound healing environment; remove all non-viable tissues including eschar, fibrin, and slough; eradicate infection; reduce edema; and reduce wound bioburden.
          • Tubigrips – Gentle compression in order to decrease edema. Patient will be monitored for clinical effectiveness and tolerance to compression. Compression will be increased in a serial fashion as indicated.
          • Wound Culture
          • Wound/Ulcer debridement – sent to pathology for histology and to rule out cancer or other confounding skin condition
          • Wound/Ulcer biopsy
          • Nutrition – We will check general laboratory tests that measure aspects of nutrition. These include serum glucose, complete blood count with platelets, prealbumin, albumin, total protein, and others as dictated by the patient’s disease. If the prealbumin level is low, we recommend dietary consult and protein supplementation. We have added Vitamin C 500mg BID, Zinc 220mg once daily, and a multiple vitamin with minerals. Zinc should not be used for more than 2 weeks, and we have told the patient to stop at that time. Prolonged zinc use may actually harm ability for the skin to heal.
          • Pressure – Offloading is very important to prevent deterioration of the patient’s current wounds/ulcers and to prevent new decubiti from forming.
            • Stage IV or equivalent low air loss mattress
            • EZ boots, Heelift boots, or other orthotics to allow the heel to be fully suspended from the bed surface. This prevents further breakdown or pressure ulcers of the heels.
            • Aggressive Q 2 hour turning regimen.
          • For all soft tissue radiation necrosis … “This patient has chronic radiation tissue injury consistent with delayed effects of ionizing radiation. This will be treated with hyperbaric oxygen therapy as described in the paragraphs below in conjunction with appropriate surgical repair.”
          • Digital photography was initiated in order to record the progress of the wounds. The wound care regimen will be modified accordingly.

          Standard Paragraphs (as appropriate):

          Please insert Dr. XXX's paragraphs as follows:

          • Risks and Benefits of Advanced Wound Care
          • Risks and Benefits of Hyperbaric Oxygen Treatments
          • Indication for Hyperbaric Oxygen …
          • Thank you, Dr. ________ for inviting us to participate in the care of this patient. We appreciate the opportunity to assist. Please do not hesitate to contact us with any questions or concerns regarding this patient’s current or future wound care.

          Finishes dictation on:

          • Patient Name
          • Medical record number
          • DOB

          Please include complimentary copies of this dictation to: 

          Thank you for transcribing.

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          NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

          REFERENCES

          1. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services . Evaluation and Management Services . 2017;.
          Topic 1177 Version