It is Possible to Standardize Wound Ostomy Continence Documentation with a Mobile App

Clinical Problem

There was a lack of standardized documentation across three hospitals regarding Wound, Ostomy, and Continence nursing care resulting in:

•  Increased time consumption
•  Increased costs
•  Increased propensity for error
•  Decreased time for patient care

Past Management

      Hospital 1       Used an electronic medical record (EMR) developed by a nurse with limited Wound experience and no Ostomy or Continence background.  EMR was lengthy, time consuming, redundant, and not mobile.

      Hospital 2         Used an electronic medical record developed by the hospital’s Information Technology Department with little or no input from the wound team.  The EMR lacked thoroughness, flexibility, and used non-standardized vocabulary.  The EMR was not mobile.

      Hospital 3         Used a paper based documentation form developed by a Wound Ostomy Continence Nurse that was thorough, logical, and used standardized vocabulary.  Although mobile, it was not an EMR and 2014 ready.

Purpose

Develop an EMR app that provides standardized documentation which is:

•  HIPPA compliant
•  Accurate and Logical
•  Flexible
•  Mobile
•  Cost Effective
•  Affordable
•  Using Standardized Medical Terminology
•  2014 Ready

Outcome

A mobile app was created that standardizes Wound, Ostomy, and Continence documentation for the three hospitals. 

Conclusion

It was possible to create a mobile documentation tool that met all criteria and resulted in a standardized Wound, Ostomy, and Continence Electronic Medical Documentation format.