By Christine Berke, MSN APRN-NP CWOCN ANP-BC; Nancy Hammeke Noda, BSN RN CWOCN; and Victoria Rabiola Thomas BSN RN CWOCN
Nebraska Medical Center
The advent of the electronic health record, the focus on systematic nursing documentation, and the need for efficient but thorough charting obligated our wound/ostomy department staff to begin a quality improvement project to develop a more efficient and consistent ostomy care documentation system at our acute care facility.
In 2007, our department identified substantial inconsistencies in documentation among the multiple board-certified wound and ostomy nurses working in our acute care facility. During chart audits mandated by our facility’s nurse practice council, our varied styles/depth of ostomy care documentation became evident. Documentation was found in different locations within the chart. Unless the same ostomy nurse cared for the same patient throughout the patient’s hospital stay, it was difficult to share and follow teaching concepts and goals for the patient’s care.
A documentation system was created based on facility documentation policies. This system has gone through annual reviews with at least two major revisions and is currently being converted to our facility’s newest electronic health record system.
In preparing for this project, we consulted the current text being used by the Wound, Ostomy and Continence Nursing Education programs (WOCNEP) approved by the Wound, Ostomy and Continence Nurses Society (WOCN), specifically the chapters on preoperative and postoperative management and stoma management.1,2
We located an internet source that consisted of an ostomy survey form created by a well-known enterostomal therapist, Mike D’Orazio, ET.3
Literature searches were conducted in Medline, CINAHL, and Google Scholar using the key terms ostomy care
, nursing documentation
, standardized documentation
, and nursing forms
. This review of the professional literature did not identify published articles relating specifically to ostomy care documentation in a standardized format.
At the outset, the team identified three requirements necessary for the ostomy documentation system based on our facility policy and personal nursing experience. The first was standardization of documentation. We had several board-certified ostomy nurses in our department with varying years of experience. Chart audits of our documentation over a sample period before this project identified that each ostomy nurse was documenting more or less than each other in varying formats (eg, Subjective, Objective, Assessment, Plan [SOAP] versus narrative notes) and in varying locations within the patient medical record (eg, provider progress note section versus nurses note tabs versus old electronic system).
Need to be concise.
A second requirement identified for documentation was conciseness, so consecutive assessments and education sessions could easily be tracked without reading volumes of notes. It was important to identify what had been assessed and/or taught previously to provide consistent counseling and education to the ostomy patients as well as capitalize on the time spent with the patient since length of stay is usually short/limited. It also assured the management team our limited time was spent focusing on and monitoring patient outcomes in preparation for patient discharge and resolution of identified problems.
Electronic health record compatibility.
Lastly, our department administration requested that our documentation system be easily adapted to a new electronic health record being created for our facility.
Developing the Documentation Instrument
Initially, we developed a single form to document a standard ostomy assessment and care consultation that included teaching documentation. We quickly recognized this form was not usable for documentation of pre-operative marking consultations nor the indepth teaching frequently needed; a second form was developed to address these special areas of focus.
In the process of having the documentation system reviewed and approved by the facility’s Form Committee, we were instructed to separate the assessment and care consultation note from the education section to meet the facility policy requirements for documenting patient education. The forms committee recognized that board-certified ostomy nurse consultants provided the majority of the ostomy patient teaching, but the staff nurses still needed to be able to monitor what instruction needed to be reinforced. The final documentation system consisted of three forms that addressed 1) pre-operative ostomy site marking and education, 2) ostomy care consultation, and 3) ostomy education and counseling (see Figures 1, 2, and 3). We feel the system is self explanatory and easy to follow.
Our department has been using this ostomy documentation system for all in- and outpatient ostomy documentation for approximately 5 years. Updates have been made during annual reviews of the documentation system and corresponding facility nursing policy. The system meets the documentation requirements we initially identified for standardization and conciseness. Information is readily located and easy to track between consultation visits. The information is inclusive and concise.
The forms have decreased documentation time and ensured essential assessment points have been addressed at each care consult visit. Currently, the paper forms are scanned into our existing electronic health record, allowing information to be accessed from any facility computer to provide consistent, patient-centered care across all care settings within our system. Audits completed by our department leadership show improved efficiency in time for documentation and consistency in documentation of outcomes for ostomy patients. Incidental feedback from other healthcare providers, including physicians, surgeons, residents, nurses, and nursing team leaders, has been positive — all of have encouraged us to share the results of this improvement project. Many of the WOC nursing students who have completed required precepted learning activities at our facility also have provided positive feedback regarding documentation system use.
Once the documentation system is converted to our electronic health record, an additional goal is to review the newly developed ostomy taxonomy systems for documenting and identifying peristomal skin problems. As the validation research and literature grows for these new clinical assessment systems, we hope to incorporate one of them into our documentation system.
The authors acknowledge and thank our nursing administration team, the Wound Ostomy department management, lead nurses, and wound colleagues at The Nebraska Medical Center for their support and encouragement in this endeavor.
1. Carmel JE and Goldberg MT. Preoperative and posteroperative management. In: Colwell JC, Goldberg MT, Carmel JE (eds). Fecal and Urinary Diversions: Management Principles.
St. Louis, MO: Mosby;2004:207–235.
2. Colwell JC. Principles of stoma management. In: Colwell JC, Goldberg MT, Carmel JE (eds). Fecal and Urinary Diversions: Management Principles.
St. Louis, MO: Mosby; 2004:240–259.
3. D’Orazio M. Ostomy Clinic Survey. Available at: http://woundostomycontinence.com/mike/ostomysurveyforpatient.pdf. Accessed April 23, 2012.