Include the following policies and procedures for documenting OASIS M1342 --Status of Most Problematic and Observable Surgical Wound.
(M1342) Status of Most Problematic (Observable) Surgical Wound
- 0 – Newly epithelialized
- 1 – Fully granulating
- 2 – Early/partial granulation
- 3 – Not healing
The purpose of this question is to identify, track, and quantify the level of healing for any observable healing wound. One common mistake made with this particular question is that a fresh wound without any observable complications (e.g., a very recent knee replacement wound) is considered to be in a healing stage, however, since we are determining a baseline at the start of care to track the wound, “Not healing” is actually the correct response. We want to establish a baseline at the start of care and then track its progress from that point forward throughout that patient’s care period.
- Determine which surgical wounds are observable.
- Includes all surgical wounds (as defined in M1340 guidance) that are not covered with a non-removable dressing/device, such as a cast.
- 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 no longer a surgical wound.
- Openings in the skin adjacent to the incision line caused by the removal of staples or sutures are not to be considered as part of the surgical wound for M1342.
- Identify the most problematic observable surgical wound.
- The “most problematic” surgical wound may be the largest, the most resistant to treatment, an infected surgical wound, etc., depending on clinical judgment and the specific situation.
- If the patient has only one observable surgical wound, that wound is the most problematic.
Reponses (From OASIS Guidance Manual):
Response “0 – Newly epithelialized”: Enter Response 0 when the wound bed has completely covered with new epithelium; no exudate; no avascular tissue (eschar and/or slough); no signs or symptoms or infection. Epithelialization is characterized by "Epidermal resurfacing" and means the opening created during the surgery is covered by epithelial cells. If epidermal resurfacing has occurred completely, the correct response in the OASIS would be "Newly epithelialized" until approximately 30 days of complete epidermal resurfacing have passed without complication, at which time it is no longer a reportable surgical wound.
Enter Response 0 – Newly epithelialized for implanted venous access devices and infusion devices when the insertion site is healed and without signs and symptoms of infection.
Response 1 – Fully granulating: Enter Response 1 when a surgical wound has a wound bed filled with granulation tissue to the level of the surrounding skin; no dead space, no avascular tissue; no signs or symptoms of infection; wound edges are open.
Response 2 – Early/partial granulation: Enter Response 2 when ≥25% of the wound bed is covered with granulation tissue; there is minimal avascular tissue (that is, <25% of the wound bed is covered with avascular tissue); no signs or symptoms of infection; wound edges open.
Response 3 – Not healing: Enter Response 3 when wound has ≥25% avascular tissue OR signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound edges OR persistent failure to improve despite appropriate comprehensive wound management.