Ostomy Medical Record Documentation Tips

Medical Record Documentation TipsOstomy is a surgically created opening in the body (i.e. a stoma) for the discharge of body wastes. It is performed when a medical condition is very severe and ostomy offers a better alternative. Ostomy surgery may involve some short-term and long-term complications, including; parastomal hernia, prolapse, stenosis, retraction, parastomal varices, skin conditions, and metabolic disturbances.

The absence of adequate ostomy care may result in patients not developing self-care skills, which in turn may lead to depression and/or social isolation, as well as increased healthcare needs and expense.

Along with providing quality wound care, stoma care nurses should also record and update information in patient health records regularly. They assess and monitor the condition of the stoma and coordinate post-operative teaching of stoma care. After surgery, the condition of the stoma should be observed every 4 hours. The nurse should also offer follow-up at regular intervals to re-assess the needs of the person with a stoma.

Tips to Document Ostomy

Patient records should be clearly updated to specify that the diversion is an intestinal or urinary ostomy, whether it’s temporary or permanent, and the location – abdominal quadrant, skin fold, umbilicus. Ostomy nurse specialists can choose to use a wound specialized EMR to document the pre-operative, post-operative assessments and follow up.

Documentation should also include:

  • the type of stoma (loop-two openings through one stoma, end-one stoma or double barrel-two distinct stomas)
  • the overall appearance (shiny, taut, edematous, dry, moist, pale, textured, smooth, bloody)
  • presence of stents, rods, drains (include type and location)
  • the color of the ostomy stoma (red, beefy red, pink, pale pink, purple, blue, black) and shape (round, oval, budded)
  • presence or absence of odor; strong, foul, pungent, fecal, musty, sweet
  • number of lumens, stenosis, or stricture and location (straight up, side, level with skin, or centrally located)

Also note whether the stoma and peristomal skin junction is intact or separated. Stoma or peristomal skin complications including mucocutaneous separation, stenosis, necrosis, bleeding, dermatitis, folliculitis, contact dermatitis, pouch leakage and infection should be mentioned in the report.