adequate of acute wound care doumentation of surgical patients

CLINICAL ISSUES

An audit of the adequacy of acute wound care documentation of

surgical inpatients

Jan Gartlan, Anne Smith, Sue Clennett, Denise Walshe, Ann Tomlinson-Smith, Lory Boas and

Andrew Robinson

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.

Key words: audit, documentation, medical records, medical staff, nursing staff, wound care

Accepted for publication: 24 March 2010

Introduction

Accurate wound assessment and wound documentation by

ward staff is central to effective wound management and best

practice (Sterling 1996, Birchall & Taylor 2003). Wound

care is commonly a multidisciplinary concern, although it is

often seen as a nursing responsibility (Lait & Smith 1998).

Overseas research suggests that wound documentation in

inpatient notes is generally poor (Hon & Jones 1996, Sterling

1996, Bachand & McNicholas 1999, Bethell 2002, Birchall

Authors: Jan Gartlan, MBBS, BMedSci, Research Fellow, Discipline

of General Practice, Clinical School, University of Tasmania; Anne

Smith, RN, Dip.Hlth.Sc., Clinical Nurse Consultant Wound Care,

Royal Hobart Hospital; Sue Clennett, RN, Clinical Nurse Manager,

Royal Hobart Hospital; Denise Walshe, BN, RN, Clinical Advisory

Coordinator, Tasmanian Department of Health and Human Services;

Ann Tomlinson-Smith, RN, Grad.Dip. Burns Nursing, Royal Hobart

Hospital; Lory Boas, RN, Royal Hobart Hospital; Andrew

Robinson, PhD, RN, School of Nursing and Midwifery, University

of Tasmania, Hobart, Tas., Australia

Correspondence: Andrew Robinson, School of Nursing and

Midwifery, University of Tasmania, Private Bag 121, Hobart, Tas.

7001, Australia. Telephone: +61 3 6226 4735.

E-mail: [email protected]

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214 2207doi: 10.1111/j.1365-2702.2010.03265.x

& Taylor 2003), but little is known about the documentation

of wounds in patient progress notes in Australian hospitals.

This study takes up this issue and aims to investigate wound

care documentation by medical and nursing staff and

determine how closely these compare with recognised stan-

dards.

Background

Formal wound assessment is a necessary part of effective

wound management (Lait & Smith 1998). It is commonly

agreed that accurate, regular wound assessments are required

to ensure that progress, or lack of progress, in wound healing

is identified quickly (Foster & Moore 1999). The Australian

Wound Management Association (AWMA) (2002) has pub-

lished written standards that set clear guidelines in the

management of wounds both acute and chronic in aetiology.

The standards highlight the importance of accurate wound

assessment and comprehensive documentation to achieve best

practice wound management. They also indicate that accu-

rate documentation of wound assessment and management

facilitates effective communication in the multidisciplinary

health care team and as such is central to patients receiving

appropriate ongoing wound management.

The AWMA standards set out clear criteria for wound

care, including the necessity for a comprehensive assessment

of the individual, their wound, their risk of wounding and the

healing environment (AWMA 2002, p. 7). Table 1 shows the

wound characteristics listed in this criterion, which should be

included in a wound assessment and then documented. The

other criteria addressed include ongoing assessments of

wound healing progress, an individualised plan of care and

documentation, which is a comprehensive and legal record.

There is clear support for the contemporaneous documen-

tation of wound care (Briggs & Banks 1996). Accurate

documentation of wound characteristics can provide a

baseline for subsequent changes (Briggs & Banks 1996,

Foster & Moore 1999, Miles 2003) and can assist in mapping

care during the wound management process (Hess 2005).

Wounds are constantly changing because of physiological

processes, meaning that measuring wound healing progress

can be difficult and good documentation is therefore essential

to ensure continuity of care. In hospitals, where it is common

for several medical and nursing staff to be involved in a

patients wound care (Briggs & Banks 1996, Hon & Jones

1996, Miles 2003), good documentation can facilitate com-

munication between health care workers (Parker & Gardner

1991). Wound documentation is also necessary for legal

purposes as it provides a legal record of care administered

(Idvall & Ehrenberg 2002, Benbow 2007) and enables the

assessment of wound management or standards of wound

care to be undertaken retrospectively (Hon & Jones 1996).

Most commonly, wound care is documented in patient

progress notes, which usually provide a retrospective account

of patient care (Griffiths 1998), focusing on completed tasks

and procedures (Gregory et al. 2008).

Despite these imperatives, a range of research studies

demonstrate that wound care is poorly documented by staff

in hospital progress notes. For example, Birchall and Taylor

(2003) report on an audit of 80 patient records in a trauma

unit. Sixty-seven wounds were identified, 40 of which had a

surgical aetiology. In the surgical wound group, only one of

the 40 wounds had a wound assessment documented, while

only 16 had dressing type documented. Similarly, Bachand

and McNicholas (1999) report the findings of the Illinois

Department of Public Health survey of general wound

documentation undertaken by hospital staff, which revealed

that documentation of wound assessment was inconsistent,

incomplete and scattered throughout inpatient medical

records. The survey findings also highlighted that it was

difficult to decipher wound assessments and monitor the

documented progress of wounds, despite an expectation that

wound assessments be documented at each dressing change.

Inconsistent use of terminology was also noted by Keast et al.

(2004) who reviewed (and proposed a new framework for)

clinically useful wound measurement approaches in response

to a lack of uniformity in assessment terminology. Further,

research conducted by Sterling (1996) and Hon and Jones

(1996) showed that the care of chronic ulcerative wounds is

poorly documented by nurses in progress notes when

compared with a structured wound assessment chart (e.g.

Table 1 The Australian wound management association standard

3.1

A comprehensive assessment of the individuals, their wound, their

risk of wounding and the healing environment

The individual with a wound will receive a comprehensive

assessment that reflects the intrinsic and extrinsic factors specific

to each individual and which have the potential to impact on

wound healing or potential wounding

A wound assessment will be performed and result in documented

evidence of: type of wound and aetiology of wounding

Location of wound

Dimensions of wound

Clinical appearance of the wound

Amount and type of exudate

Presence of infection, pain, odour or foreign bodies

State of surrounding skin and alterations in sensation

Physiological implications of wounding to the individual

Psychosocial implications of wounding to the individual and

significant others

J Gartlan et al.

2208 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214

the PUSH tool, see George-Saintilus et al. 2009). Sterlings

(1996) study showed that while the position and source of

chronic ulcerative wounds were documented in 96% of the

26 audited progress notes, other wound features such as

appearance, exudate, odour, wound pain and progress were

documented in only 42% or fewer cases. Hon and Jones

(1996) reported similar results in an audit of 40 patient notes

with wounds healing by secondary intention. In this case,

dressing type was the most frequently documented part of

wound management, with wound dimensions, wound

appearance features and wound pain documented in less

than 25% of notes. The ability to recognise and classify tissue

type and condition has also been found to be lacking in both

doctors and nurses (Stremitzer et al. 2007), an important

absence, because tissue evaluation is just as critical (p. 161)

as other elements in the assessment. The existence of

problems with wound documentation is further supported

by Bethell (2002), who found a persistent lack of documen-

tation by both nursing and medical staff with respect to the

care of pressure ulcers.

Despite this evidence, we found no published research

specifically auditing the documentation of wound care by

medical staff alone and little comparing medical and nursing

wound documentation. Stremitzer et al. (2007) note that

records made by nurses are often better than those made by

doctors and suggest that this is because doctors often

assign treatment of chronic wounds to nursing staff [and

thus gain] little knowledge based on practical experience of

modern chronic wound management methods (p. 158).

Nonetheless, research has been reported which addresses

medical staff documentation in hospital medical records

related to other conditions, such as the recording of risk

factors after coronary bypass surgery and the documenta-

tion of delirium in elderly patients with hip fracture (Wright

& Strang 1997, Milisen et al. 2002). However, these studies

highlighted that medical staff made important omissions in

documentation and that in some areas of care documenta-

tion was poor. With respect to nurses, there are numerous

articles which address the problems they face with regard to

documenting patient care. Reasons for poor nursing docu-

mentation can include a lack of time (Owen 2005), nursing

staff shortages (Owen 2005), lack of mentorship from more

experienced nurses (Bakalis & Watson 2005), the task-

focused nature of nursing work (Goopy 2005) and the oral

culture of nursing (Hopkinson 2002) which undermines

imperatives to facilitate documentary reporting. Hullin

et al.s (2008) audit of nursing forms underlined the

disparity between formal and informal documentation and

noted that there were inconsistencies in current forms,

structure and flow of requisite documentation. Harding

et al. (2007) also raise the possibility that documentation is

becoming too complex and that clinicians will find the

process too time-consuming (p. 2).

In Australia, we found no published research investigat-

ing the documentation of wound care by nursing and

medical staff in hospital progress notes. This article will

present the findings of a project which are intended to

address this gap, particularly in relation to acute wound

care documentation.

Methods the study

Aim

The purpose of this study is to examine the degree to

which acute wound care documentation by nursing and

medical staff in a regional Australian hospital meets the

standards set by the AWMA (2002). The focus is on

documented clinical history with regard to the wound,

wound characteristics, evidence of a management plan and

factors such as wound pain. Other components of the

standards, such as risk of wounding and documentation

of the physiological and psychosocial implications of

wounding to the individual, are outside the scope of this

study.

Methodology

In 2006, the inpatient progress notes of 49 randomly selected

inpatients requiring acute wound care were retrospectively

audited for wound care documentation by hospital nursing

and medical staff. An acute wound was defined as a wound

caused by surgical incision, trauma or burn that had occurred

within two weeks prior to admission or during the admission

to a surgical unit at the hospital.

Audit tool development and data collection

The research team used the AWMA written standards

(AWMA 2002) as a guide to develop the paper-based audit

tool. Our initial intent was to assess wound documentation

made by nurses in the patients medical record against criteria

developed from AWMA standards of wound management

(Table 1). The key focus was wound documentation associ-

ated with dressing changes, and for surgical patients this is

the time when wound assessment and interventions take

place.

To undertake the audit, the research team developed a pilot

audit tool to record the nursing documentation of wound

care during the first seven days and on discharge day of an

Clinical issues An audit of acute wound care documentation

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214 2209

inpatient stay. A seven-day audit period was chosen given the

short stays generally associated with surgical admissions.

Prior to administration, the tool was sent to five Australian

experts in either wound care or audits for feedback. The

primary feedback from the reviewers related to potential

difficulties in auditing the documentation associated with the

physiological and psychological implications of wounding to

the individual. These areas were subsequently removed from

the audit tool. The revised tool included assessment of clinical

history in relation to the wound and documentation of the

physical characteristics of a wound (including wound dimen-

sions, exudate and exudate characteristics, wound margins,

wound bed and state of surrounding skin), evidence of an

individualised plan of management, and other factors such as

wound pain, skin sensation and dressing type. The tool was

piloted during early 2006, a process which involved an audit

of 15 inpatient progress notes.

The findings revealed a general paucity of nursing wound

documentation and the efficacy of the audit tool and audit

procedures with three exceptions. First, the pilot demon-

strated that in the context of integrated hospital progress

notes, the narrow focus on nurses wound documentation

meant it was impossible to assess the adequacy of the overall

wound documentation, because medical staff also docu-

mented wound care/management. To address this problem,

we expanded the scope of the audit to include medical staff

wound documentation. Second, the pilot also revealed the

importance of auditing wound care documentation at a

patients admission to the surgical unit to determine baseline

wound assessment documentation. We subsequently modi-

fied the audit to facilitate the collection of these data. Finally,

because many patients audited in the pilot had an admission

which extended well beyond seven days, the audit period was

expanded to include the first 14 days and discharge day of an

inpatient stay.

Sample

Following the pilot process and subsequent revision of the

audit tool, hospital progress notes were audited of patients

who required treatment for an acute wound caused by

surgical incision, trauma or burn and who were admitted

for two or more nights to one of two surgical units in the

hospital. The sample of patients notes was randomly

selected by a nursing staff member on the unit after the

patients admission and the medical records requested.

Following admission, the archived progress notes were

audited either in the medical records department or on the

surgical ward itself by the first author using the revised

audit tool.

Ethics approval

Use of the audit tool was approved by the University of

Tasmania Health and Medical Ethics committee, approval

no. H0008379.

Validity and reliability/rigour

The audit tool was developed specifically for the purposes of

this study and has not been validated. As outlined earlier, it

was sent out for expert review and piloted on a sample of 15

inpatient progress notes and consequent revisions made.

Data analysis

The data were analysed using the software package SPSSSPSS

version 13.0 (SPSS Inc., Chicago, IL, USA) to produce

descriptive statistics.

Results

Forty-nine inpatient medical progress notes were audited.

The mean age of the audited inpatients was 545 years (SD

213). Twenty-nine (59%) were men. The inpatients had a

mean length of 96 days in hospital (SD 90). Thirty-four

(70%) wounds were surgical incisions, 14 (29%) were

traumatic requiring surgical intervention and one (2%) was

traumatic with no surgical intervention.

Audit of wound documentation on admission to surgical

unit

Twenty-five (51%) inpatients had preoperative admission for

elective surgery. All of these inpatients had a surgical wound.

The remaining 24 (49%) inpatients had a formal documented

admission by a doctor and/or nurse on their presentation to

the unit.

Table 2 (below) shows the frequency of wound character-

istics documentation by medical and nursing staff on patient

admission to the surgical unit, when the wound was viewed

by either a doctor, nurse or both. Seventeen inpatients (35%)

had a wound that was viewed by a doctor at admission to the

unit. Twelve of these wounds had documentation by a nurse

to suggest they had also visually inspected the wound during

the inpatients admission. Seven of the 12 inpatients who had

a wound that had been seen by a doctor and a nurse had

wounds that were traumatic in origin and required surgical

intervention. The remaining five inpatients whose wounds

had been viewed by both a doctor and nurse had wounds

with a surgical aetiology.

J Gartlan et al.


On admission, there were some areas of wound assessment

that doctors documented more frequently than nurses in

admissions, namely wound dimensions (in over 40%), wound

bed (in over 40%), state of surrounding skin (in over 50%)

and management plan (in 100% of cases). Nurses docu-

mented exudate more frequently than doctors (in over 40%

of admissions compared to less than 20% of admissions

documented by doctors). Nurses also documented dressing

type more frequently than doctors: for 42% of admissions

compared with 29%. Nurses did not document any infor-

mation about wound dimensions, wound bed or local skin

sensation at any admissions. Nurses recorded information

about wound margins in less than 10% and state of

surrounding skin in less than 20% of admissions.

Column 3 of Table 2 shows that when combining the

documentation made by doctors and nurses when both

review the same wound at admission, the only substantial

increase in frequency of documentation is with wound pain at

75%, dressing type at 67% and state of surrounding skin at

67%. Three quarters of admissions had no documentation of

wound margins at admission and more than half had no

documentation of wound dimensions, exudate and wound

bed by doctors and nurses. When a wound was seen by both

doctors and nurses at the initial presentation, the most

frequently documented wound characteristic was the state of

the surrounding skin, which was noted in more than 50% of

medical records.

Dressing change audit

One hundred and twenty-two dressing changes were docu-

mented by nurses in the medical progress notes during the 49

admissions within the audit period. One hundred and three

dressing changes were documented by medical staff. Seventy-

three dressing changes (60%) for wounds were reviewed by

both medical and nursing staff. The mean number of days

between dressing changes for all wounds was 18 (SD 13).

Wounds with a surgical aetiology were dressed more

frequently than traumatic wounds with a mean of 16 days

(SD 11) between dressing changes. Traumatic wounds had a

mean of 23 days (SD 16) between dressing changes.

Table 3 shows the frequency of documentation of wound

characteristics by medical and nursing staff during dressing

changes. The combined documentation column refers to the

Table 2 The frequency of medical and nursing staff documentation of wound assessment on admission to the surgical unit when the wounds

were viewed

Wound characteristic

Documentation

by doctors

n = 17 (%)

Documentation

by nurses

n = 12 (%)

Documentation by doctors or nurses

when both review the wound

n = 12 (%)

Non-documentation by

doctors and nurses at admission

n = 17 (%)

Dimensions 7 (41) 1 (8) 4 (33) 9 (53)

Exudate 3 (18) 5 (42) 5 (42) 13 (76)

Wound margins 3 (18) 1 (8) 3 (25) 14 (82)

Wound bed 8 (47) 1 (8) 5 (42) 9 (53)

State of surrounding skin 9 (53) 2 (17) 8 (67) 6 (35)

Wound pain 7 (41) 5 (42) 9 (75) 6 (35)

Skin sensation 4 (24) 0 (0) 2 (17) 12 (71)

Management Plan 17 (100) 10 (83) 12 (100) 0 (0)

Dressing type 5 (29) 5 (42) 8 (67) 8 (47)

Table 3 The frequency of documentation of wound characteristics by medical staff and nursing staff during dressing changes

Wound characteristic

Documentation by

medical staff

n = 103 (%)

Documentation

by nursing staff

n = 122 (%)

Non-documentation by medical

and nursing staff

n = 137 (%)

Dimensions 2 (2) 2 (2) 136 (99)

Exudate 20 (19) 21 (17) 89 (65)

Wound margins 30 (29) 19 (16) 92 (67)

Wound bed 17 (17) 9 (7) 112 (82)

State of surrounding skin 12 (12) 10 (8) 115 (84)

Wound pain 27 (26) 53 (43) 58 (42)

Skin sensation 0 (0) 2 (2) 134 (98)

Management plan 85 (83) 95 (80) 6 (4)

Dressing type 17 (17) 57 (47) 54 (39)



dressing changes that had a documented wound assessment

by both a doctor and nurse at the same dressing change.

Comparing medical and nursing staff documentation

(Table 3), the audit found that medical staff were marginally

more likely to record information about wound margins and

wound bed at a dressing change. Nursing staff more

frequently documented information about wound pain and

dressing type. Both had similar rates of recording other

aspects of the wound assessment.

Examining the results of the combined documentation

reveals that a wound management plan is recorded at most

dressing changes by medical and nursing staff. Information

about wound pain is recorded in 60% of dressing changes,

when the wound is seen by both medical and nursing staff.

However, information about wound bed and the state of

surrounding skin is not documented in over 75% of dressing

changes and in 60% of dressing changes, there was no

documentation about wound exudate and wound margins.

Wound dimension and skin sensation are recorded in less

than 5% of assessments by both doctors and nurses at the

same dressing change. Those areas of wound assessment

documentation that increase significantly when both medical

and nursing staff look at the same wound are wound exudate,

wound pain and management plan. The other aspects of

wound assessment documentation do not increase in fre-

quency of documentation when wounds are seen by both

doctors and nurses.

Comparing the documentation by medical and nursing

staff when both review the same wound at admission and

dressing changes (Tables 2 and 3) shows that all aspects

except wound margins are recorded more frequently at

admission. The frequency of recording of wound dimensions,

state of surrounding skin and skin sensation drops signif-

icantly at dressing changes when compared with admissions.

Wound exudate description was classified into four areas:

type, amount, colour and odour (Table 4). Overall, wound

exudate descriptions were poorly documented, being re-

corded in less than 50% of dressing changes when an exudate

was present. The amount of exudate was the most frequently

recorded description of exudate. Nursing staff described

exudate features particularly type and amount more

frequently than medical staff. Exudate colour and odour were

recorded at only five dressing changes, with nursing staff

recording it in four of the five instances.

Discussion

This is a useful exploratory study investigating acute wound

care documentation by hospital medical and nursing staff on

two surgical units in a regional public hospital. It addresses a

gap in Australian research about the current state of play of

wound assessment and management recording. It is unique

in its comparison of medical and nursing staff documentation

as well.

The study is limited by its small sample size, particularly

the small number of wounds seen at admission. A further

limitation is that the audit tool, which was specifically

designed for the purpose of the study, was not validated. We

attempted to overcome this study weakness by piloting the

tool and receiving feedback from experts in the research field

and wound care.

A further weakness is that we did not distinguish between

acute wounds that heal by primary intention and those that

heal by secondary intention. Our audit did not collect specific

details about the nature of the wounds except whether they

were surgical or traumatic in aetiology because of the ethical

issues surrounding potential participant identification. It may

be argued that straightforward incision wounds that heal by

primary intention do not require the same degree of wound

assessment and documentation as more complicated wounds

that may require more complicated intervention, for example a

third-degree burn requiring skin grafting. The AWMA stan-

dards do not address this issue, simply stating that all wounds

require comprehensive wound assessment and documentation.

The audit was also limited by what was written in the

notes, and non-written wound assessments were not investi-

gated. The auditor could not always identify from the notes

whether wounds had been viewed (because nurses may have

viewed the wound and made an oral report, viewed the

wound and made no report, or not viewed the wound),

therefore the number of wound assessments may have indeed

been higher than the audit showed. The audit could not

measure other methods of wound care communication such

as nursing handover or ward round discussion.

Finally, the study findings are limited, because the audit

could not encompass an evaluation of the accuracy of wound

assessments or of wound complications. Hence, we could

not validate the accuracy of any documentation. This is

important because the relative absence of wound care

Table 4 Wound exudate description recorded by medical staff and

nursing staff at wound assessment during dressing changes when an

exudate was documented as present

Exudate

characteristic

Frequency documented

by medical staff

n = 20 (%)

Frequency documented

by nursing staff

n = 21 (%)

Type 2 (17) 9 (43)

Amount 2 (17) 16 (76)

Colour 1 (8) 3 (14)

Odour 0 (0) 1 (5)

J Gartlan et al.


documentation does not necessarily equate to poor wound

care (Griffiths & Hutchings 1999), whereas discrepancies

between the actual care provided and that recorded have been

noted (Ehrenberg et al. 2001). The limitations of this study

meant we were unable to address these issues.

Nevertheless, the audit revealed that medical and nursing

staff documentation of acute wound characteristics at

admission and during dressing changes is clearly inadequate

when compared to the AWMA standards (AWMA 2002). It

is concerning that many aspects of the wound assessments are

not documented on admission; such documentation provides

a baseline against which wound healing can be evaluated. It is

also interesting that combining the documentation of assess-

ments by medical and nursing staff at admission and dressing

changes only increased a few areas of wound assessment

documentation and not every aspect overall, hence gaps

remained in the documentation.

The finding that wound assessment documentation associ-

ated with dressing changes is also incomplete is supported in

overseas research (Hon & Jones 1996, Sterling 1996,

Bachand & McNicholas 1999, Bethell 2002, Birchall &

Taylor 2003). We found it interesting that wound dimensions

are only recorded at 4% of dressing changes, because the

measurement of wounds is a critical indicator of wound

healing (Hess & Kirsner 2003). Moreover, successive mea-

surements provide a valid way of monitoring the progression

of wound healing.

It is also interesting that the main area of the wound

assessment that was documented at admission and dressing

changes was the management plan, especially because doc-

umented wound assessments play an important role in

supporting the management plan (Birchall & Taylor 2003).

This may indicate that nursing and medical staff value the

inclusion of management plans in the notes over wound

assessment records. We acknowledge that documenting

management is an integral part of wound care, but we raise

doubts about the validity of management plans without

complete and well-documented assessment to justify them.

There is research supporting the use of staff tools, such as

a standardised wound assessment chart (Keast et al. 2004,

George-Saintilus et al. 2009), which allows wound care

documentation to be more effective and easier to use. There

is some evidence supporting the value of a chart, with some

studies showing that charts provide for more comprehensive

wound assessments than hospital progress notes (Sterling

1996), as well as bringing other benefits, such as acting as a

teaching tool (Saunders & Rowley 2006). There has been a

focus in the literature more recently on a movement towards

computerised documentation systems (Kyhlback & Sutter

2007, Wild et al. 2008, Owen 2005). This is also not without

problems such as the cost and the time it will take to

implement (Owen 2005) or the need to tailor systems to

local-level work practices (Kyhlback & Sutter 2007). A

further barrier to implementing new documentation systems

is resistance to change; this may occur at the individual or

group level, including among the nursing profession itself

(Curtis & White 2002, Timmons 2003, Cork 2005).

Conclusions

As acute wounds have the potential to become chronic

wounds, the accurate documentation of wounds assessments

is important to facilitate communication between staff

members and ensure wound care follows best practice as

stated in wound care guidelines. It seems that the current

standard of wound assessment documentation in hospital

progress notes by nursing and medical staff is low. This

suggests that acute wound documentation is not a priority to

the staff in surgical wards and that written communication

may be deemed less important and less effective. Although

wound management plans are viewed as more significant

parcels of information, they are not validated with docu-

mented wound assessments.

Relevance to clinical practice

It is apparent that more work needs to be carried out in

hospitals to ensure wound documentation conforms to best

practice standards. The findings of this study suggest that the

gap between the evidence and current practice has not

diminished over the last decade, indicating that existing

attempts to address the problem have not been effective. It is

possible that activities need to be undertaken in hospitals,

engaging medical and nursing staff in collaborative processes

to identify the issues that underpin poor wound documenta-

tion and to implement interventions to ensure best practice is

achieved.

Acknowledgements

We acknowledge the funding received from the Royal

Hobart Hospital Research Foundation, the PHCRED RDP

fellowship, and Petya Fitzpatrick and Jacinta Stewart for

their input to the study.

Contributions

Study design: JC, AS, SC, DW, AT, LB, AR; data collection

and analysis: JG, AS, SC, DW, AT, LB, AR and manuscript

preparation: JG, AS, AT, LB, AR.



Conflict of interest

No conflict of interest is known.

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