Does this person have a surgical wound??? - PowerPoint Presentation

Slide1

Does this person have a surgical wound???

M1340

Identifies the presence of a wound resulting from a surgical procedure.

For the purpose of this OASIS item, a surgical site closed primarily (with sutures, staples, or a chemical bonding agent) is generally described in documentation as a surgical wound until re-epithelialization has been present for approximately 30 days, unless it dehisces or presents signs of infection.

After 30 days, it is generally described as a scar and should not be

included

in this item.

YES

Most surgical incisions

Orthopedic pin sites

I&D with drain

I&D only if there was excision of necrotic mass, abscess, mesh or other appliances or structures (beyond a simple I&D)Wound with drain even after drain pulledHave, punch or excisional biopsySurgical repair in internal traumaTake down of ostomy

Pressure ulcer with muscle flap

Dialysis catheter exit site

Implanted infusion devised

ON-Q catheter sites

LVAD exit site

Implanted pumps

Cardiac Cath by cut down

Pacemaker until epithelialized for 30 days

VP shunt

Donor site for grafts

Arthroscopy

NO

I&D with no drain

Debridement

Repair of traumatic laceration

Burn with skin graftAny wound ending with otomy/ostomyOstomy allowed to close on its own Pressure ulcer with skin graftsPressure ulcer sutured closed

Arthrocentesis/thoracentesis/paracentesis sites utilized for simple aspiration of fluid

PICC line (tunneled or non-tunneled)

Cardiac Cath by needle procedure

Toenail removal

Pacemaker or internal defibrillator once epithelialized for 30 days

Cataract surgery

Gynecological surgery via vaginal approach

Mucus membranes

Skin graft recipient site

Status of healing definitions apply to surgical wounds healing by primary intention and to those healing by secondary intention.

Response 0:

Newly epithelialized

: Completely covered with new skin, no exudate, no avascular tissue (eschar and/or slough); no sign or symptoms of infection

Note: Surgical incisions healing by primary intention do not granulate! Because of this the only responses the could be appropriate are 0-Newly Epithelialized or 3- Not healing!Response1: Fully Granulating: wound bed filled with healthy granulation tissue to the level of the surrounding skin, no dead space, no avascular tissue, no sign of infection, edges are openResponse 2: early/Partial granulation: > or = 25% of wound bed is covered with granulation, this is some avascular tissue, no s/s of infection, edges are open.

Response 3:

not healing

: >or = 25% avascular tissue OR s/s of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound edges OR persistent failure to improve despite appropriate wound management.

M1342 :Status of Most problematic (Observable) Surgical Wound

Misc. stuff

SCABS

Does not automatically mean non-healing

First determine if the wound is healing by:

Primary intention (not healing)

Secondary intention (consider all 4 healing status choices.

Vascular Access Devices

If held open by drains, lines or needle, cannot fully granulate and may remain “non-healing” while that device is in place.

Implanted Venous Access Devices (port-a-

cath

)

When first implanted they are surgical wound. Then follow guidelines of healing.

M1340 Does the patient have a surgical wound?

0- No

1- Yes, patient has at least one (observable) surgical wound

2- Surgical wound known but not observable due to non-removable dressing or device.

THE ONLY TIME TO USE THIS ANSWER IF IS THERE IS A PHYSICIAN ORDER TO NOT REMOVE!