DOCUMENTATION
Nursing documentation is the cornerstone of best practice (Benbow, 2011). The NMC (2021) states that “good record keeping is an integral part of nursing and midwifery practice and is essential to the provision of safe and effective care”. Good documentation provides evidence of care and communication, supports service delivery, effective clinical judgements and decision making (Benbow, 2009).
Accurate and comprehensive wound care documentation at each dressing change is essential to establish a serial record of healing or deterioration (Benbow, 2016). The importance of accurate, timely and legible record keeping is highlighted by the Nursing and Midwifery Council Guidelines for Record Keeping (NMC, 2021).
High quality record keeping will help nurses give skilled and safe care. According to the Nursing and Midwifery Council guidelines (NMC, 2021), record keeping and documentation should demonstrate the following:
- Clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been.
- Completed records as soon as possible after the event has occurred.
- Records have not been tampered with in any way.
- Entries made in paper records are clearly and legibly signed, dated and timed.
- That records are kept securely.
Additional information should be documented for patients with pressure ulcers/injuries, such as identified risk factors, when the damage was first observed, and repositioning schedules (NICE, 2014; 2020). Also included should be the grade of ulcer, preventative measures, type of mattress supplied and the clinical management and evaluation of care of the patient.
EPUAP (2019) suggest that for effective pressure ulcer/injury prevention and management, clinicians must produce a comprehensive patient assessment, which includes:
- Risk assessment
- Skin assessment
- Nutrition for pressure ulcer/injury prevention
- Mobility for the prevention of pressure ulcers/injuries
- Support surfaces assessment
- Special population assessment
(EPUAP, 2019)
Quality documentation is essential, as it is primarily to direct appropriate day to day care to ensure continuity of the patient's care. Documentation is a record of events and needs to be effective to ensure the continuity of care. Health care notes are a tool of communication that provide clear evidence of planned care (NMC, 2016).
A treatment plan can be formed based on a complete assessment that can attempt to remove any factors that may delay healing. Any changes to the treatment plan must be documented, and a rationale for any change recorded.
This module has demonstrated that wound assessment is a complex issue that must involve assessment of the patient. It is important to re-assess the wound at regular intervals and to document the results. This is a particularly helpful way to track the progress of a wound, and to communicate with your colleagues to ensure that patients are receiving continuity of care.
Holistic wound assessment enables the clinician to identify any specific underlying causal factor, the type of wound, signs of healing and consider the wound bed and surrounding skin. Identifying baseline information will assist in making an informed decision and a pathway of care.