An audit of the adequacy of acute wound care documentation of surgical inpatients

Abstract

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.

Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

“…2007), variables of clinical policies or guidelines (Considine & Potter 2006, Junttila et al. 2010, Gartlan et al. 2010) or standardized terminologies (Lunney 2006, Hayrinen et al.…”

“…2000, Ehrenberg & Birgersson 2003, Baath et al. 2007), assessment of physical characteristics of wound (Gartlan et al. 2010), specific assessment and interventions for older patients with chronic heart failure (Ehrenberg et al.…”

Health professionals’ decision‐making in wound management: a grounded theory

“…, Gartlan et al . ). ‘Expert decision‐making’ was characterized by the health practitioner's ability to focus on the important aspects of the situation.…”

“…'practice-based knowledge' (Luker & Kenrick 1992). Several researchers have described the difficulties inherent in defining wound care decision-making by nurses in terms of the 'novice' and the 'expert' and the salience of making the 'correct' decision (Lamond & Farnell 1998, Birchall & Taylor 2003, Keast et al 2004, Gartlan et al 2010. 'Expert decision-making' was characterized by the health practitioner's ability to focus on the important aspects of the situation.…”

Implementation of Concurrent Nursing Audit: An Experience Report

“…11 The errors in the nursing notes suggest ineffective communication among the professionals, which can harm the patients in the development of the treatment. 12 Thus, the implementation of the audit can equip the nursing team and strengthen the importance of the nurse auditor in this process through actions and orientations, besides the elaboration of tools for care planning.…”