The documentation of wounds in an acute hospital setting

Abstract

This article presents the findings of research into the documentation of wounds healing by secondary intention, in an acute hospital setting. The benefits of recording the nursing assessment of a patient's wound, together with the legal and professional implications of poor documentation, are outlined. The points that specialists writing on the subject identify as necessary when describing a wound within the nursing records are highlighted. A survey is described in which descriptions of wounds healing by secondary intention were collected from the nursing records on six acute wards in a hospital, and then measured against an assessment tool. For each criterion selected for investigation, the number of occurrences was recorded, thus providing a quantitative description of the documentation of wounds. The findings indicated deficits in many of the areas selected. While statements such as 'healing well' were commonly used, descriptions which would provide information about the state, progress or management of the wound were generally omitted.