CLI NI CAL I SSUES

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 ndings 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 ndings 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: Andrew.Robinson@utas.edu.au
2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214 2207
doi: 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 identied 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 difcult 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 (Grifths 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 identied, 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 ndings 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 ndings also highlighted that it was
difcult 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 reects the intrinsic and extrinsic factors specic
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
signicant 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
specically 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 ow of requisite documentation. Harding
et al. (2007) also raise the possibility that documentation is
becoming too complex and that clinicians will nd 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 ndings 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 dened 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 rst 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 ve Australian
experts in either wound care or audits for feedback. The
primary feedback from the reviewers related to potential
difculties 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 ndings revealed a general paucity of nursing wound
documentation and the efcacy 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-
ed 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 rst 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 rst 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 specically 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 SPSS SPSS
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-ve (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 ve inpatients whose wounds
had been viewed by both a doctor and nurse had wounds
with a surgical aetiology.
J Gartlan et al.
2210 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214
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)
Clinical issues An audit of acute wound care documentation
2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214 2211
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 signicantly 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 classied 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 ve dressing changes, with nursing staff
recording it in four of the ve 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 specically
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 eld
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 specic
details about the nature of the wounds except whether they
were surgical or traumatic in aetiology because of the ethical
issues surrounding potential participant identication. 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 ndings 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.
2212 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214
documentation does not necessarily equate to poor wound
care (Grifths & 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 nding 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 benets, 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 (Kyhlba ck & 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 (Kyhlba ck & 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 signicant
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 ndings 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.
Clinical issues An audit of acute wound care documentation
2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214 2213
Conict of interest
No conict of interest is known.
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