Aims and objectives: This study examined the degree to which acute wound care documentation by doctors and nurses meets the standards set in the Australian Wound Management Association guidelines, focusing on clinical history with regard to the wound, wound characteristics, evidence of a management plan and factors such as wound pain.
Background: Wound care documentation is an important component of 'best practice' wound management. Evidence suggests that wound documentation by hospital staff is often ad hoc and incomplete.
Design: Survey.
Method: An audit of acute wound care documentation of inpatients admitted to a surgical ward was conducted in 2006 using the progress notes of 49 acute inpatients in a regional Australian hospital. The audit focused on wound documentation on admission and during dressing changes.
Results: The findings demonstrated that, whereas doctors and nurses documented different aspects of the wound on admission, three quarters of patients had no documentation of wound margins and over half had no documentation of wound dimensions, exudate and wound bed. Whereas 122 dressing changes were documented by nurses and 103 by doctors, only 75 (60%) were reviewed by both medical and nursing staff. Doctors and nurses tended to document different aspects of dressing changes; however, in more than half the cases, there was no documentation about wound bed, margins, exudate and state of surrounding skin, whereas wound dimensions and skin sensation were recorded in less than 5%.
Conclusion: Wound care documentation by doctors and nurses does not meet the Australian standard. The findings suggest there is ineffective communication about wound care in the multidisciplinary setting of the hospital.
Relevance to clinical practice: The article concludes that hospitals need to engage medical and nursing staff in collaborative processes to identify the issues that underpin poor wound documentation and to implement interventions to ensure best practice is achieved.