Wound EMR for Holistic Assessment of Patients with Wounds

It is important to perform a holistic assessment of the patient while managing acute or chronic wounds. If you fail to appropriately assess wounds and provide optimal care, it will result in delayed healing time, increased risk of infection, and inappropriate use of wound dressing. This can negatively impact the quality of life of the patient. An electronic medical record system specific to wound care plays a vital role in this assessment since it allows nurses to collect the information via observation, questioning, physical examination and clinical investigations in a comprehensive and systematic manner and retrieve the info quickly when they need it.

Holistic assessment actually involves the assessment of the patient, the wound, the factors affecting wound healing and the environment in which the patient lives and functions. To be more specific, this includes the assessment of the following factors:

  • Systemic Factors: Assessment of etiology, duration, and decreased oxygenation or perfusion of the wound as well as co-morbid conditions, medications, and host infection of the patient.
  • Psychosocial Factors: Assessment of the patient’s knowledge deficits, cultural beliefs and financial constraints such as lack of or insufficient health insurance. It is also necessary to assess whether the patient has impaired access to appropriate resources and any social support from family, significant others or community resources.
  • Local Factors: Assessment of desiccation, excess exudates, low wound temperature, recurrent trauma (also friction and pressure), infection, and necrosis and foreign bodies.

Documenting the above factors allows nurses to assess the wound properly and provide proper care or communicate with wound care specialists regarding any problems. Wound assessment charts that can be accessed by both wound care physicians and nurses should be provided. These charts act as a guidance tool for evaluating a wound. Even so, assessment charts will not provide any understanding of underlying abnormalities, medical conditions or medications that may affect the process of wound healing. It requires the physical examination and history report to know these details.

Why Wound EMR is a Better Choice for a Holistic Approach

With paper charts, it is time consuming to document or retrieve these details as the nurses have to check huge piles of files. When it comes to general EMR, you may find different kinds of templates and fields that you don’t need. It takes time to find the fields you want. However, wound EMR is customized with the library of required forms and templates, and designed according to the wound care practice so that you can easily choose the fields to enter data and find the fields to retrieve data. A wound EMR with an interface for physicians and nurses, and which supports mobile platforms can perform efficient review of all relevant wound data, whether for a personal, remote or real-time consult. Holistic assessment with wound EMR can provide you with the following benefits:

  • Efficient allocation of physician time by allowing specialized wound physicians to treat more patients while others focus on patients in their respective specialties.
  • Easy wound documentation with specific templates results in lower administrative costs. It allows physicians and nurses to spend more time caring for their patients.
  • With optimal wound care, the length of stay can be reduced.
  • Patients can receive more efficient and higher quality care owing to specialized treatment from wound specialists, earlier identification of wounds and treatments and less dislocation.

The capability of a reliable wound EMR system to generate customized reports further enhances its significance in providing efficient wound care with holistic assessment.