Background: Wound care documentation is an essential component of best practice wound management in order to enhance inter-disciplinary communication and patient care. However, evidence suggests that wound care documentation is often carried out poorly and sporadically.
Objectives: Determine postoperative wound assessment documentation by acute care nurses and explore their perception of factors constraining adequate nursing documentation.
Methods: A two-phase sequential exploratory mixed methods design was used. Phase one: A retrospective clinical chart audit of nurses' documentation was undertaken. A random selection of 200 medical records were reviewed over 3 months at a provincial hospital in Vietnam. Phase two: semi-structured interviews were conducted with 13 surgical nurses to explore their perceptions of factors influencing appropriate documentation. Inductive qualitative content analysis was applied for qualitative data. This manuscript adheres to COREQ guidelines for reporting the qualitative phase.
Findings: Phase one: 200 records were audited. Less than 10% of preoperative factors (such as co-morbidities, smoking and nutrition status) related to the risk of delayed wound healing were documented. During the first 5 days postoperation, there was no documentation about incision location, wound dimension, wound bed (in wounds healing by secondary intention) or odour. In less than 10% colour and type of exudate were recorded. Phase two: Emerging key categories were: unimportance of nursing documentation, difficulty to change existing practice, and personal factors.
Conclusion: This study indicated that surgical wound assessment documentation was insufficient and inconsistent among nurses. Nurses viewed the wound assessment documentation as unimportant. Therefore, extensive exploration of strategies is required to enhance the quality of wound assessment documentation.
© 2020 John Wiley & Sons Ltd.