Transforming WOC Documentation in an Electronic World

Technology has changed the way health information is recorded and communicated   between health professionals.  The WOC nurse department at a comprehensive cancer center was faced with the task of personalizing an Electronic Medical Record system to meet the documentation needs for the WOC  nurse as well as the physician and bedside nurse colleague’s. 

Comprised of both inpatient and outpatient clinical areas, our facility epitomizes the ‘continuum of care’.   Following inpatient discharge, our patients are followed in the outpatient clinics for their further needs in their journey to cure or comfort.  The maintenance of this continuity generated an enormous necessity for consistent documentation and monitoring of wounds and pressure ulcers and access to a comprehensive documentation tool for communication amongst practitioners. 

A standardized documentation format for wound, ostomy, skin, and continence care was developed.  WOC assessment and treatment recommendations can be clearly stated in both flow sheet and summary format.  Wound measurements, including tunneling, undermining, and periwound skin condition, can be documented on the flow sheet and transformed into a graph view to trend the progression. 

The most beneficial result of the EMR documentation/flow sheet is the ability to monitor wound healing with ease, even after the patient has been discharged.  Previous documentation in a paper record resulted in a time consuming search through multiple documents to find assessment and measurement data.  All assessments and measurements are now organized and can be trended to evaluate the current treatment regimen and make treatment plan revisions accordingly.

Sharing of this process may assist other WOC nurses involved in electronic documentation in developing their own customized documentation tools.