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. References Australian Wound Management Association (2002) Standards for Wound Management. Cambridge Publishing, West Leederville, WA. Bachand P & McNicholas M (1999) Creating a wound assessment record. Advances in Wound Care 12, 426429. Bakalis NA & Watson R (2005) Nurses decision-making in clinical practice. Nursing Standard 19, 33. Benbow M (2007) Wound care, audit and patient involvement. Journal of Community Nursing 21, 20, 22, 24. Bethell E (2002) Incidence and prevalence data: can we ensure greater accuracy? Journal of Wound Care 11, 285. Birchall L & Taylor S (2003) Surgical wound benchmark tool and best practice guidelines. British Journal of Nursing 12, 1013. Briggs M & Banks S (1996) Documenting wound management. Journal of Wound Care 5, 229. Cork A (2005) A model for successful change management. Nursing Standard 19, 4042. Curtis E & White P (2002) Resistance to change: causes and solu- tions. Nursing Management 8, 1520. Ehrenberg A, Ehnfors M & Smedby B (2001) Auditing nursing content in patient records. Scandinavian Journal of Caring Sciences 15, 133141. Foster L & Moore P (1999) Acute surgical wound care. 4: the importance of documentation. British Journal of Nursing 8, 288. George-Saintilus E, Tommasulo B, Cal C, Hussain R, Mathew N, Dlugacz Y, Pekmezaris R & Wolf-Klein G (2009) Pressure ulcer PUSH score and traditional nursing assessment in nursing home residents: do they correlate? Journal of the American Medical Directors Association 10, 141144. Goopy SE (2005) Taking account of local culture: limits to the development of a professional ethos. Nursing Inquiry 12, 144. Gregory L, Millar R, Tasker N & Tranter S (2008) Nurse led ini- tiative to improve assessment and documentation. Australian Nursing Journal 16, 19. Griffiths P (1998) An investigation into the description of patients problems by nurses using two different needs-based nursing mod- els. Journal of Advanced Nursing 28, 969977. Griffiths J & Hutchings W (1999) The wider implications of an audit of care plan documentation. Journal of Clinical Nursing 8, 5765. Harding K, Gray D, Timmons J & Hurd T (2007) Evolution or revolution? Adapting to complexity in wound management Inter- national Wound Journal 4(Suppl. 2), 112. Hess CT (2005) The art of skin and wound care documentation. Home Healthcare Nurse 23, 502. Hess CT & Kirsner RS (2003) Uncover the latest techniques in wound bed preparation. Nursing Management 34, 54. Hon J & Jones C (1996) The documentation of wounds in an acute hospital setting. British Journal of Nursing 5, 10401045. Hopkinson JB (2002) The hidden benefit: the supportive function of the nursing handover for qualified nurses caring for dying people in hospital. Journal of Clinical Nursing 11, 168. Hullin C, Monaghan V, Searle C & Gogler J (2008) The chaos in primary nursing data: good information reduces risk. In HIC 2008 Conference: Australias Health Informatics Conference; The Per- son in the Centre, August 31September 2 2008, Melbourne Convention Centre (Grain H ed.). Health Informatics Society of Australia, Brunswick East, Vic., pp. 109113. Available at: http:// search.informit.com.au/documentSummary;dn=385155869901283; res=IELHSS (accessed 5 May 2010). Idvall E & Ehrenberg A (2002) Nursing documentation of postop- erative pain management. Journal of Clinical Nursing 11, 734 742. Keast D, Bowering K, Evans A, MacKean G, Burrows C & dSouza L (2004) MEASURE: a proposed assessment framework for devel- oping best practice recommendations for wound assessment. Wound Repair and Regeneration 12, s1s17. Kyhlba ck H & Sutter B (2007) What does it take to replace an old functioing information system with a new one? A case study International Journal of Medical Informatics 76(Suppl 1), s149 s158. Lait ME & Smith LN (1998) Wound management: a literature review. Journal of Clinical Nursing 7, 11. Miles M (2003) Problems identified in gaining non-expert consensus for a hypothetical Wound Assessment Form. Journal of Clinical Nursing 12, 824833. Milisen K, Foreman MD, Wouters B, Driesen R, Godderis J, Abra- ham I & Broos P (2002) Documentation of delirium in elderly patients with hip fracture. Journal of Gerontological Nursing 28, 2329. Owen K (2005) Documentation in nursing practice. Nursing Stan- dard 19, 48. Parker J & Gardner G (1991) The silence and the silencing of the nurses voice: a reading of patient progress notes. The Australian journal of advanced nursing: a quarterly publication of the Royal Australian Nursing Federation 9, 3. Saunders K & Rowley J (2006) Implementing a wound assessment and management system (WAMS). Australian Nursing Journal 13, 3133. Sterling C (1996) Methods of wound assessment documentation: a study. Nursing Standard 11, 38. Stremitzer S, Wild T & Hoelzenbein T (2007) How precise is the evaluation of chronic wounds by health care professionals? Inter- national Wound Journal 4, 156161. Timmons S (2003) Nurses resisting information technology. Nursing Inquiry 10, 257269. Wild T, Prinz M, Fortner N, Krois W, Sahora K, Stremitzer S & Hoelzenbein T (2008) Digital measurement and analysis of wounds based on colour segmentation. Acta Chirurgica Austriaca 40, 510. Wright J & Strang JR (1997) Reducing the risk after coronary artery bypass surgery: documentation of risk factors and communication between hospital and general practice. Public Health 111, 157. J Gartlan et al. 2214 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 22072214 This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.