IDT Notes

[txdon]

My facility policy is to write an IDT note on every person with a non-pressure wound. We are expected to write a note weekly until healed. The problem is I have multiple residents with non-pressure non-healing wounds that remain status quo. I need help writing a good note that will address the fact nothing has changed with this wound, but want to have all basis covered with survey. I thought about addressing the wound monthly unless otherwise indicated. Any thoughts?

My second question involves a resident with Tardive Dyskinesia. He has significant EPS and I need suggestions on how to write a good note addressing this. The EPS is non-reversible and I know several facilities have been tagged for not addressing it. Any suggestions?

[CapeCodMermaid, RN]

Non-healing or not, the standard of practice is a note AT LEAST weekly on any wound. You should document that you have changed the treatment every 14 days. Get the MD to write a progress note as to why the wound isn't healing.

EPS is another story. Are you doing an AIMS test every 6 months to make sure it's not getting any worse?

[pixie120]

For EPS/TD I would ask the psychiatrist to eval and write a note to address what type/duration/going to get worse/any other ways to relieve it. I know that Zyprexa can/does mask some EPS/TD, and if its deemed permanent, what are the adaptive devices that might make quality of life better? IE severe tremor-weighted spoon/fork to offset tremor, lip plate, lipguard on plate for tremor hands, and mouth movements, bendable straw (I would ask OT to look, they are the specialists in adaptive equipement). Important to document what meds he/she is onnow that won't cause worse EPS/TD (again psychiatrist can help) or nuerologist can document.

Wounds: Make sure a qualified wound specialist has deemed it as "non-healing" or diabetic specialist, and then chart routinely what "supportive" care you are providing, elevation, pressure reduction (even on non-pressure wounds there can be pressure components),pressure reducing mattress, heelz up, note the regular stuff about any wound, be sure to address "no s/sx infection" or send culture regularly to rule out infection.

[pixie120]

I would ask Medline representative and/or the Medicare B billers of treatment supplies (ask medline rep) for their RN wound specialists to look at any wounds and provide advice. WOund center should be involved as well, at least for the initial "non-healing" part and making recommendations for ways to heal it.