What information should be included when documenting a History of Present Illness (HPI) for a skin substitute?

Documentation of History of Present Illness (HPI) for Skin Substitute Application

When documenting an HPI for skin substitute application, you must include the wound's onset and chronology, precise location and size (percentage of body surface area), quality and depth (full-thickness vs. partial-thickness), severity with functional impact, duration of non-healing, context of wound development, prior treatments attempted with their effectiveness, and a comprehensive assessment of factors affecting wound healing including vascular status, infection, and patient comorbidities. 1

Essential Wound-Specific Elements

Wound Characteristics

• Onset and chronology: Document when the wound first appeared, its progression over time, and any patterns of improvement or deterioration 1
• Location: Record the anatomic site with precision (e.g., plantar aspect of right foot, medial malleolus) and whether it involves critical structures 1
• Size and extent: Measure and document the wound dimensions in centimeters and calculate percentage of body surface area involved using standardized charts (Lund and Browder) 2
• Depth: Specify whether the wound is partial-thickness (involving epidermis and dermis) or full-thickness (extending through dermis into subcutaneous tissue or deeper) 3, 4
• Quality: Describe the wound bed characteristics including presence of granulation tissue, slough, eschar, exposed structures (tendon, bone), and wound edges 1

Wound Healing Context

• Duration of non-healing: Document how long the wound has been present and specifically note if it meets criteria for chronic wound (typically >4 weeks without healing) 2, 3
• Context of wound development: Record the mechanism of injury (traumatic, surgical, burn, pressure, diabetic ulcer, venous insufficiency) 1, 4
• Modifying factors: Identify what makes the wound better or worse, including offloading, dressings, or activities 1

Medical History Critical for Skin Substitute Use

Comorbidities Affecting Wound Healing

• Diabetes mellitus: Document type, duration, glycemic control (HbA1c), and presence of neuropathy or vasculopathy 2, 5
• Vascular disease: Record history of peripheral artery disease, prior revascularization procedures, ankle-brachial index results, and presence of palpable pulses 5
• Renal disease: Note chronic kidney disease stage as this affects wound healing 5
• Immunosuppression: Document conditions or medications causing immunocompromise 5
• Nutritional status: Record albumin levels, weight loss, or malnutrition 1

Prior Treatment History

• Standard wound care attempts: Document all previous treatments including debridement, offloading devices, compression therapy, negative pressure wound therapy, and their duration 2, 1
• Previous skin substitutes: Note if cellular, acellular, or autologous grafts were previously attempted and their outcomes 2
• Surgical interventions: Record any prior revascularization, debridement procedures, or reconstructive attempts 5
• Duration of standard care failure: Specifically document that the wound has failed to heal with standard of care for an appropriate timeframe (typically 4+ weeks) 2

Medication Documentation

Current Medications

• All prescription medications: Include names, dosages, frequencies, and duration of use 1, 5
• Anticoagulation: Document warfarin, direct oral anticoagulants, or antiplatelet agents as these affect surgical planning 5
• Immunosuppressants: Record corticosteroids, biologics, or chemotherapy agents 5
• Over-the-counter medications and supplements: Include these as they may interact with wound healing 1, 5

Medication Allergies

• Hypersensitivity reactions: Document any allergies to bovine products (relevant for collagen-based substitutes), antibiotics, or topical agents 1, 5

Functional Impact and Quality of Life

Impact on Daily Activities

• Mobility limitations: Document inability to ambulate, need for assistive devices, or activity restrictions 1
• Self-care abilities: Record impact on bathing, dressing, and wound care management 6
• Pain assessment: Use numeric scales (0-10) and describe pain quality (sharp, burning, constant vs. intermittent) 1
• Work and social function: Note days missed from work or social isolation due to wound 1

Social and Environmental Factors

Living Situation and Support

• Home environment: Document ability to maintain wound care at home, presence of caregivers, and access to follow-up 1, 6
• Tobacco and substance use: Record current and past tobacco use (pack-years), alcohol consumption, and recreational drug use as these impair wound healing 5
• Occupational exposures: Note work-related factors that may affect wound healing or recurrence 5

Infection Assessment

Signs of Infection

• Clinical indicators: Document erythema extending beyond wound margins, purulent drainage, increased warmth, fever, or systemic signs of infection 2
• Culture results: Include any wound culture data showing bacterial colonization or infection 2
• Prior infections: Record history of osteomyelitis, cellulitis, or sepsis related to the wound 5

Documentation of Medical Necessity

Justification for Skin Substitute

• Failure of standard care: Explicitly state that the wound has not responded to standard wound care including appropriate debridement, infection control, moisture balance, and offloading for a specified duration 2
• Wound characteristics requiring advanced therapy: Document that the wound is full-thickness, has adequate vascular supply, is free of active infection, and has a clean granulating base suitable for skin substitute application 2, 3
• Expected outcomes: Note the goal of using skin substitute (e.g., to provide structural support, deliver growth factors, accelerate healing, prevent amputation) 2, 3

Pertinent Negatives

Important Absent Findings

• No signs of active infection: Document absence of purulent drainage, fever, or systemic signs if wound is clean 1
• No critical ischemia: Note presence of adequate perfusion if vascular status is acceptable 1
• No exposed vital structures: Record if bone, tendon, or joint are not exposed (or document if they are) 1

Common Pitfalls to Avoid

Insufficient documentation of standard care failure: The most critical error is failing to document that standard wound care has been attempted for an adequate duration (typically 4+ weeks) before applying skin substitute, as this is required for medical necessity 2.

Inadequate wound bed preparation documentation: Failing to document that the wound has been adequately debrided, is free of infection, and has adequate vascular supply will result in denial of coverage, as skin substitutes require a prepared wound bed 2, 3.

Missing functional impact: Not documenting how the wound affects the patient's quality of life, mobility, and daily activities weakens the justification for advanced therapy 1.

Incomplete vascular assessment: Omitting documentation of peripheral pulses, ankle-brachial index, or prior vascular studies in patients with arterial insufficiency is a critical gap, as skin substitutes will fail without adequate perfusion 5.