Foto-Dokumentation

Photo wound documentation

Time-saving, efficient and directly at the point of treatment thanks to digital, mobile solution

The treatment of wounds and thus also their documentation is an integral part of everyday nursing care. Chronic wounds affect around 800,000 people in Germany every year. It is not uncommon for wound documentation to still take place in analog form on sheets of paper. Where digitization has already taken hold, the documentation workflow is often interrupted by a media break. The textual description, the photo of the wound and the assignment to the patient take place on different media, separated in time and space. In addition to medical necessity, wound documentation is also essential for financial accounting of treatment. Since the length of stay for patients is fixed at a flat rate, proof of the need for a longer stay must be provided. Only then can the additional costs incurred be billed. The evidence is checked on a random basis by the medical service of the health insurance fund. If a wound is the cause of an extended stay, its documentation can be such proof. This article explains how wound documentation via an app on a mobile device can make the process more efficient and safer and offers advantages for the patient as well as for the hospital staff.

Wound documentation presents challenges in several areas. First of all, in the fast-paced daily hospital routine, the simple, safe and time-saving execution of documentation is of central importance. One safety aspect lies in the correct assignment of documentation to the patient, which is particularly critical when the workflow is separated by time and location. By using an app for wound documentation, this could be created on a mobile device directly at the point of treatment and assigned to a patient. Patient data should be imported from the HIS and not have to be entered manually for each documentation. This saves time and prevents incorrect entries and patient mix-ups. Once documentation is complete, it should be possible to save it in the HIS and PACS, making it immediately available.

Furthermore, it is important that the wounds are described as comprehensibly and objectively as possible in order to perceive all relevant changes and to prevent a loss of knowledge through personnel changes. Photographing the wound should therefore be firmly integrated into the documentation process. By using a mobile device with a camera, photography can be seamlessly integrated into the documentation process.

Manual entry of parameters during documentation is time-consuming and can lead to errors due to subjective assessments as well as staff-dependent deviations. Automated recording of certain parameters is therefore an exciting aspect of digitization and can speed up, standardize and objectify documentation. Based on the photo, for example, the wound can be automatically measured using a segmentation algorithm. Automatic, structured keywording based on the classification of wound photos would also be conceivable. Such algorithms, often based on artificial intelligence, are part of active research areas that are gradually finding their way into clinics.

The clear presentation of daily photo and wound documentation over time is an opportunity for digitization and offers great added value for patient treatment. The healing process can thus be better understood and assessed. Changes in the wound can be perceived more quickly and, if necessary, treated accordingly.

The fully digital and mobile solution for wound documentation can accelerate and simplify the process, relieve staff and at the same time increase the quality of the recorded data. With the photo wound documentation, mRay already offers a manual module. To make the process even more convenient, we are already working on an extension to include automated wound documentation as part of a research project, which will again significantly reduce the time required and at the same time increase accuracy. We will keep you informed in this regard.

Alexandra Ertl | Research & Development

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