The clinician documented application of calcium alginate to a Stage 2 pressure ulcer in the sacral region, while the physician’s written wound care order in the medical record specified application of Triad paste. This discrepancy was identified during coding review and brought to the attention of the home health agency. If the wound care order was changed verbally by the physician, supporting documentation such as a telephone order or signed physician communication should be present in the medical record.
Use of a dressing that differs from the physician-ordered treatment may result in inappropriate wound management, delayed healing, skin maceration, increased risk of infection, and inaccurate evaluation of wound progress.
If wound care interventions are not performed according to current physician orders, the skilled need for nursing services may be questioned and unresolved wound issues may lead to additional visits, emergency care, or hospitalization.
CMS requires that care be provided in accordance with physician orders and that all verbal or telephone orders be promptly documented and authenticated. Failure to reconcile discrepancies between documented treatment and physician orders may be cited as deficient clinical documentation and inadequate coordination of care.
Verify whether a physician-approved order change was obtained. If so, ensure the medical record includes a signed verbal or telephone order reflecting the updated wound care instructions. If no supporting order is present, the discrepancy should be corrected to align documentation with the physician’s written order.
If plan of care is given properly the business impact will be less.
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© Copyright 2025 Bharari Digital Solutions (BDS). All Rights Reserved
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