BACKGROUND:
An increased volume of patients across a range of contracted facilities had increased documentation time. The increased documentation time impinged upon patient care time. The volume of patients in conjunction with the variety of documentation practices used by the contracted facilities increased the propensity for human error and decreased the WOC Nurse’s consistency in documentation. All facilities either had or were in the process of procuring Electronic Medical Records (EMRs), none of which facilitated the specialties of Wound, Ostomy, or Continence.
OBJECTIVES:
1. Reduce documentation time
2. Increase patient face-to-face time
3. Insure consistency and accuracy of documentation
METHOD:
1. Researched proper documentation methods and the required peripheral universal documentation tools necessary for accurate documentation, as a means of improving time efficiency while insuring consistency
2. Created a software ready documentation method
3. Researched software methods to discover the most efficient point of care documentation practice
4. Researched how the software ready documentation could be translated into a mobile documentation application
RESULTS:
A mobile documentation app was created meeting all the initial objectives. The app fuses assessment, treatment-plan construction, and W.O.C. documentation.
1. Documentation time is reduced
2. Patient face-to-face time is increased
3. Consistency and accuracy is insured
4. Mobility facilitates ease of use
5. App is compatible with all existing EMRs