Wound, Ostomy and Continence Care Documentation Requirements
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by Janis E. Harrison, RN, BSN, CWOCN, CFCN
The events that happened next are blurry, but I kept a diary to document our experience.
As I was pushed from the room where my husband was coding, I was met by a tiny little nun, we'll call Sister. She tried to move me to a waiting area nearby but I knew I was not going to step away from the door. They had not listened to or assessed my husband during a very concerning time and he was supposed to be in post-op recovery.
I remember a very rude surgical patient in the same recovery pod with my husband that kept using his call light to get more food and banter with the nurses. So they were not readily answering the light. Sister kept insisting I move away from the door so the Nurses and doctors could get in the room to help my husband. I was backed away enough to stay out of the way. I was not going to let my husband go that easily. I wanted to be there if I had to say goodbye. I just wanted to hold his hand and breathe life back into his body.
The next thing I knew the doctor from anesthesia told me they were taking Daryl back to surgery and as the surgeon was scrubbing for another surgery, he was ready for this emergency. All I could think was "You mean Daryl is alive?" The answer was "Yes." And we had to hurry back to surgery to stop his hemorrhage. They let me in to run down the hall and hold his hand and kiss him. My wonderful husband was showing his good humor by placing his hand and one finger in the air whirling it around saying "Look out, Emergency Hernia surgery coming through." I was crying and laughing as the surgery staff took him away from me once again.
Sister took me to the Surgery waiting room and sat with me for a short time. I sat crying quietly and praying. I then felt what I thought was a consoling hand on mine. It was an elderly lady that started telling me how her 95 year-old dying husband had been in the ICU unconscious for weeks. All I could think was this is not the time for me to have to console someone else. Being a nurse makes you want to care for all patients and their families. But this time, I was the family member.
I had no one to sit with me, no phone, and no support. My husband's parents, as well as my own, were out of town. I finally found a phone and called my sister, a nurse as well, to be with me as I did not want to be alone if I was were to lose my soul mate. She arrived in less than 30 minutes after a trip that would normally take an hour.
A Need for Accurate Medical Documentation
The surgeon met me again in the little consultation room and said the bleeding was under control and my husband would be in recovery for 60 minutes then he would be moved to ICU for the night. They had suctioned over 3 liters of blood from his abdomen. Blood would be replaced during the night with infusions.
I would enter his room and sit by his side as much as I was allowed for the next 48 hours. He began to tell me his story of being asked if he wanted to stay or go. He chose to fight and get back to me and our boys. Yes, he had encountered a white light experience.
Daryl was moved to the surgical floor after two days in ICU. As I sit here reading the diary, tears flow as I write. This was the beginning of my passion for accurate documentation.
These were the first two surgeries of so many more to come.
Documentation Necessities in the Event of Litigation
In today's world of litigation where some families are quick to take the medical provider or facility to court, it is imperative that our documentation be precise and detailed. Family members or patients have their electronic devices readily available for recording what is said, to take pictures, and even check medical websites for answers to their questions before we can educate them regarding the specifics of the case at hand.
Documentation on our patients is meant to be made easier by Electronic Medical Record (EMR) programs. Most of these programs are designed with the generic check mark system with small spaces provided to document incidents.
The EMR makes it easier to transfer information regarding the patient between departments, floors, facilities, and providers. Records are currently accessed on the computer while many envision tablets with apps taking their place and enhancing mobility, speed, and accuracy. Bedside report and charting is supposed to make documentation efforts easier. Documenting at the time of each assessment should also keep your records timely and accurate. Those days of keeping little notes in our pockets should be over.
What a Wound, Ostomy and Continence EMR Can Do For Your Facility
I had found it difficult to document properly on wounds, ostomies, and continence while consulting with many different facilities and I see as many as 17 patients in a day. At that time, every facility had a different EMR or paper record to document. Most were inconclusive or just a blank free-hand space and many items were forgotten.
I had the good fortune to be contacted by the developer of a long-term care EMR regarding wound treatment documentation. This led to my becoming the Chief Clinical Consultant for the creation of the first app-based Wound, Ostomy, and Continence documentation program. The app is a check box or fill in the blank program that prompts the nurse to answer a vast majority of the pertinent information. This information is easily passed between departments, floors, facilities, and providers. Four of my contracted hospitals and my nursing homes now use the app for their W.O.C. documentation. I have found I save approximately 10 minutes per patient using my tablet computer.
Accurate and detailed Wound, Ostomy, and Continence documentation will be required of each of us with the new ICD-10 codes in the ensuing months.
About the Author
Janis Harrison is the CEO and owner of Harrison WOC Services, LLC, which offers contractual Wound, Ostomy and Continence (WOC) services for hospitals, long-term care facilities and home health across Northeast Nebraska. Harrison has had numerous poster published, is a writer for Advanced Tissue's newsletter and is currently involved in developing health care documentation applications for WoundRight Technologies, LLC.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.