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Abstract: Accurate, timely wound assessment and documentation is fundamental to nursing practice. A 2005 retrospective chart audit (N = 54) at a rural, 238-bed tertiary care facility in Northeastern Pennsylvania (average daily census 175 to 180) found that complete wound assessment documentation (including measurements) was lacking in 59% of patient charts. The purpose of this quality improvement initiative, led by the Wound Ostomy Continence Nurse (WOCN), was to evaluate and improve nursing assessment and documentation of impaired skin (pressure ulcers, skin tears, open surgical wounds, diabetic ulcers, and venous stasis ulcers). A review of the literature confirmed the importance of consistency, which led to the hospital-wide implementation of education programs and “Measurement Monday.” Using AHCPR guidelines of care for pressure ulcers and beginning in January 2006 all wounds were assessed and measured every Monday and the proportion of incomplete charts declined to 38%. Following addition of a wound documentation tool in 2007, the proportion of incomplete records was 14.8%. This quality improvement initiative improved the quality and consistency of wound assessment/measurement and documentation.

Please address correspondence to Suzanne Stewart, MS, RN, CWOCN, Robert Packer Hospital, Guthrie Healthcare, 1 Guthrie Square, Sayre, PA 18840; email: stewart_suzanne@guthrie.org.

     As many as 3 million people suffer from pressure ulcers in the United States; costs can be as high as $3.6 billion.^1,2 Consistent, complete, and accurate wound assessment/measurement and documentation of compromised skin integrity, wound size, treatments, and healing progression are an important part of nursing practice.^2-5 Accurate and timely wound assessments, including measurements, are needed to help determine the best treatment plan for patients with impaired skin such as pressure ulcers, skin tears, open surgical wounds, diabetic ulcers, and venous stasis ulcers. Measurements, as included in the initial wound assessment of impaired skin, provide baseline data for tracking treatment outcomes.^2-7 Evidence in a patient’s record related to accurate and timely assessments, treatments, and documentation support that a patient has received care and may answer questions related to internal quality investigation or possible litigation.^7-10 In order to ensure accurate measurement comparison and evaluate healing over time, consistent assessment methods are necessary and reliable observations must be documented.^5,7-12

     Routine patient record monitoring at a rural, 238-bed tertiary care facility in Northeastern Pennsylvania revealed a lack of consistency with regard to documentation of the wound assessment/measurement process. The purpose of this quality improvement initiative, led by the Wound Ostomy Continence Nurse (WOCN), was to evaluate and improve nursing assessment and documentation of impaired skin.

Methods

     Literature review. In the initial phase of this quality improvement project, best practices were retrieved from the Agency on Health Care Policy and Research’s (AHCPR, now the Agency for Healthcare Research and Quality, AHRQ)³ and the Wound, Ostomy and Continence Nurses Society’s² pressure ulcer treatment guidelines. Additional literature was consulted later in the project — a literature review was conducted in October 2007 and then again in August 2008 using PUBMED (United States National Library of Medicine) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL®) and the search terms wounds, documentation, wound tools, and wound assessment.