Wound EMR Facilitates Documenting Comprehensive Medical History

While evaluating a new patient with a wound, it is imperative to obtain a comprehensive patient history. It is essential for proper wound assessment, understanding any medical issues and getting clear insights into why the wound is not healing. This information will help clinicians prepare an appropriate plan of care tailored for the patient. With electronic medical record (EMR) system designed for wound care, you can easily access the patient’s complete history in the exam room with the patient present. If you have a tablet or Smartphone, the history report can be accessed even when you are at the patient’s bed. Before exploring the role of EMR, let’s take a look at the importance of a comprehensive history report.

A comprehensive history consists of the following details that help in taking appropriate steps to ensure effective and quick wound healing.

  • Medical History – The patient’s medical history explains about allergies, laboratory studies, vascular studies, surgical procedures, medications, radiologic studies and other crucial factors related to the patient’s illness and conditions. This will help clinicians have a clear idea about any past or current medical issues the patient may have that can affect the wound healing such as diabetes, coronary artery disease (CAD), congestive heart failure (CHF), anemia, and cancer.
  • Family History – The details comprise the age and general health information of living relatives with particular attention to parents, siblings, grandparents and natural children, the cause of death and other information regarding deceased family members and any chronic diseases in the immediate family. The clinicians can gain insight into any inherited or congenital conditions or diseases and determine whether they are affecting wound healing.
  • Social History – This provides information regarding the patient’s past and current activities including marital status, current employment, living arrangements, use of drugs, alcohol or tobacco, sexual history, level of education and other social factors that may influence his/her daily activities. From this information, clinicians can identify issues that may affect wound healing. For example, chronic obstructive pulmonary disease (COPD) is most often associated with smoking and this condition leads to reduced blood flow and oxygen to the tissues that impede wound healing.
  • Wound History – This includes the list of past and current medications and dressings (both effective and failed), previous treatments, adjunctive modal (physical therapy, skin replacements and growth factors), details of any devices used and who has taken care of the wound, information regarding clinical consultation related to specialty management program for skin and wound care and other details about wound and wound care. With this information, clinicians can clearly understand the nature of the wound, analyze the strategies that have been used to facilitate wound healing and make appropriate modifications in the plan of care after consulting with the healthcare professionals who have taken care of the wound.

Useful Features of Wound EMR

Here are the major features of wound EMR that makes it an effective tool to obtain a complete patient history.

  • EMR can be easily integrated with other systems and has an interface for physicians and other nurses. This forms a centralized record system that allows caregivers to access patient data quickly and identify pertinent information.
  • Clinically-defined templates for recording the patient’s history within the electronic record system make the details easily recognizable. There are separate tabs identifying sections including history of present illness, past medical and surgical history, allergies, and family and social history.
  • Customized reports can be generated to meet specific requirements.

EMRs also allow providers to update the patient’s history details as and when changes occur and add notes to each section.