Ostomy Care Procedure Note

Date/Time of Service: [Date and time]

Author and Credentials: [Name and credentials, including WOC certification if applicable]

Care Setting: [inpatient / outpatient / ED / home health]

Encounter Type: [Ostomy care procedure / pouching system change / evaluation and teaching / troubleshooting / other] (Default to ostomy care procedure / pouching system change unless otherwise specified.)

Indication and Clinical Context

[Primary indication for encounter and brief context] (1–3 sentences stating the reason for care such as routine change, leakage/undermining, skin breakdown, poor wear time, post-op teaching, supply fitting, suspected infection, or high-output management. Specify new vs established ostomy. If symptom-driven, include patient-reported trigger with brief direct quote when it clarifies the concern.)

Ostomy Background

• Ostomy type and construction: [colostomy / ileostomy / urostomy / unknown] — [end / loop / ileal conduit / unknown] (If uncertain, describe observed stoma characteristics and explicitly state uncertainty.)
• Anatomic location: [Anatomic quadrant/site description]
• Current pouching system: [one-piece / two-piece]; [flat / soft convex / convex]; [cut-to-fit / pre-cut / moldable]; [barrier ring / paste / belt / extender strips / none] (List all known components.)
• Usual wear time: [hours / days]
• Emptying frequency: [times per day]
• Relevant prior complications or product sensitivities: [None reported / description]

Pre-Procedure Assessment

• Participation level: [independent / needs set-up / partial assist / total assist]
• Pain assessment: [pain score and location / denies pain]
• Assessment positions: [supine / sitting / standing / multiple positions] (Note if multiple positions were used to evaluate creases, folds, or retraction.)
• Consent for non-routine interventions: [obtained / not indicated / declined] for [photography / silver nitrate / debridement / other] (Include only when consent is required.)

Stoma Assessment

(Use clock-face orientation for locations and measurements in mm/cm throughout. Use objective viability descriptors; avoid non-specific terms like "healthy.")

• Size: [diameter in mm/cm; include oval dimensions if applicable]
• Protrusion height and profile: [flush / budded / protruding] — [height in mm/cm]
• Color and viability: [beefy red and moist / pale / dusky / dry / other objective descriptor]
• Edema: [none / mild / moderate / severe]
• Bleeding: [none / scant with cleansing / spontaneous]
• Mucocutaneous junction (MCJ): [intact / separation] (If separation present, document depth and extent by clock-face with measurements.)
• Special findings: [no retraction / retraction with depth / no prolapse / prolapse with length / no parastomal hernia / parastomal hernia present] (Include only if assessed.)
• Peristomal topography: [flat / creases / folds / scars / soft abdomen / firm abdomen] (Map notable features by clock-face. Include when troubleshooting leakage or fit issues.)
• Undermining on removed barrier: [none / present at clock-face locations] (Include when troubleshooting leakage.)

Peristomal Skin Assessment

(Required when pouch is removed. If pouch was not removed, state: "Peristomal skin not assessed—pouch not removed due to [reason]" and omit remaining fields.)

• Overall status: [intact / breakdown]
• Distribution: [adjacent to stoma / peripheral]; [circumferential / patchy]; [clock-face mapping]
• Morphology: [erythema / maceration / denudation-erosion / papules-pustules / satellite lesions / blisters-tears / hypergranulation / purulence] (Select all that apply.)
• Severity: [mild / moderate / severe]
• DET Score: Discoloration [0–3]; Erosion [0–3]; Tissue overgrowth [0–3]; Total [0–9] (Include if using standardized scoring.)
• Etiology impression: [concern for moisture/effluent-associated injury / concern for medical adhesive-related skin injury / concern for infectious pattern with candidal features / concern for allergic contact dermatitis] (Include when clinically indicated. Pair with objective findings that support the impression.)

Output Assessment

• Output during care: [present / absent]
• Type: [stool / urine / mucus]
• Consistency/clarity: [liquid / pasty / formed] or [clear / cloudy] for urine
• Color: [description]
• Concerning features: [none / blood / pus / sudden change / absent output with symptoms]
• Amount and frequency: [scant / moderate / large]; emptying [frequency per day]
• 24-hour measured output: [mL] from [patient log / I&O record] (Include for ileostomies, new ostomies, or high-output concerns when available.)

Procedure Performed

• Barrier removal: [gentle peel / push-pull technique / other] [with / without] adhesive remover
• Cleansing: [warm water / pH-balanced cleanser / other]; skin dried before application
• Skin protection/treatment: [barrier film / crusting with powder and barrier film / hydrocolloid sheet / none / other] (Specify locations by clock-face if targeted.)
• Stoma measurement: [size in mm/cm]; Barrier opening cut to: [size/shape]
• Pouching system applied: [one-piece / two-piece]; [flat / soft convex / convex]; [drainable / closed / urostomy]; [cut-to-fit / pre-cut / moldable]
• Accessories used: [belt / extender strips / moldable ring / paste / barrier film / none]
• Seal check at completion: [intact / reinforced / needs monitoring]; wear-time goal [duration]
• Additional treatments: [topical antifungal / silver nitrate to hypergranulation tissue / wound dressing under barrier / other] (Include consent status, location by clock-face, and observed response. Omit if none performed.)

Post-Procedure Status

• Tolerance: [well tolerated / limited by pain / limited by anxiety / other]
• Post-procedure pain: [score and location / not reassessed]
• Immediate complications: [none / description]
• Seal at end of visit: [intact / concerns for early lift at clock-face location]
• Supplies provided or ordered: [list / none]

Patient/Caregiver Education

• Participants: [patient / caregiver / both]; interpreter [yes with language / no]
• Topics covered: [normal stoma and skin expectations / measuring stoma and sizing barrier opening / wear-time schedule and early change triggers / recognizing leakage and early skin injury / output monitoring and dehydration warning signs / supply management / when to contact care team] (Select all that apply.)
• Competency assessment: [Teach-back performed: patient/caregiver accurately verbalized topics] [and/or] [Return demonstration performed: level of assistance required] (Do not document "patient understands" without an observed measure.)
• Education deferred: [reason]; next teaching opportunity [timing and setting] (Include only if education was deferred.)

Assessment and Plan

(Problem-oriented summary. Name key findings and link to objective data.)

[Problem]: [Concise assessment]

• Rationale: [Key supporting findings]
• Pouching system plan: [continue current system / change to new system with rationale]
• Skin treatment plan: [products, application schedule, and stop criteria] (Include if skin treatment indicated.)
• Wear-time plan: [target wear time and triggers for earlier change]
• Output monitoring plan: [measurement frequency, thresholds for concern, hydration guidance] (Include if output monitoring indicated.)
• Referrals/orders: [WOC clinic / surgeon / home health / nutrition / other] (Include if applicable.)

(Repeat problem-oriented section for additional problems as needed.)

Follow-up

• Timing and setting: [clinic / inpatient recheck / home visit / PRN with defined criteria]
• Return-sooner triggers: [worsening skin / inability to maintain seal / pain / suspected ischemia or necrosis / high-output symptoms or dehydration signs / fever / purulence / significant bleeding]

Urgent Findings and Escalation

[Objective signs concerning for ischemia/necrosis, mucocutaneous separation, obstruction, or uncontrolled bleeding] — [Immediate actions taken] (Include only if urgent findings present. Document prominently.)