Since nurses have a duty to keep clear and accurate records, they need to know how to measure and document wounds in order to track their progress to healing
This article, part 4 in a series on wound management, addresses the sometimes routine yet crucial task of documentation. Clear and accurate records of a wound enable its progress to be determined so the appropriate treatment can be applied. Thorough records mean any practitioner picking up a patient’s notes will know when the wound was last checked, how it looked and what dressing and/or treatment was applied, ensuring continuity of care. Documenting every assessment also has legal implications, demonstrating due consideration and care of the patient and the rationale for any treatment carried out. Part 5 in the series discusses wound dressing characteristics and selection.
Citaton: Hampton S (2015) Wound management 4: Accurate documentation and wound measurement. Nursing Times; 111: 48, 16-19.
Author: Sylvie Hampton is an independent tissue-viability consultant.
As in any aspect of healthcare provision, clear and accurate nursing documentation is essential in wound management. Regular and thorough documentation forms a record of any assessments made and care provided, changes in the condition of the wound, and any other relevant information. Having this information readily available ensures good continuity of care.
While many nurses see record-keeping as a time-consuming interruption to direct patient care, high-quality documentation need not take long to complete. In addition to improving patient safety, it can prevent time being wasted, for example, in duplicating assessments and care. In any event, it is a professional and legal requirement of nursing practice and cannot be avoided; in legal terms, if interventions are not documented, they did not happen.
No matter how skilled or experienced the nurse, inaccurate or incomplete documentation can lead to patient harm and could lead to legal proceedings against the nurse (Austin, 2011). Such cases often rely on expert witnesses to assess whether care was adequate; these witnesses will largely rely on documentation to do this.
Documentation in practice
Section 10 of the Nursing and Midwifery Council’s code (NMC, 2015) clearly outlines nurses’ record-keeping responsibility (Box 1). However, the task of documentation is not necessarily limited to registered nurses – they can delegate to healthcare assistants, assistant practitioners and nursing students to document the care they have given (Royal College of Nursing, 2012) – see Box 2. Delegation of record-keeping follows the same principles as any other delegated task in healthcare settings, requiring ongoing supervision as appropriate. Contrary to the common myth, registered nurses are not required to countersign notes made by unregistered staff and students if they are confident that:
- The HCA, AP or student has been trained to appropriate standards and is competent to produce such records as part of the overall provision of care;
- It is in the patient’s best interests for the HCA, AP or student to do so (RCN, 2012).
As members of the wider healthcare team, HCAs, APs and student nurses take personal accountability for good record-keeping. They must keep clear accurate and timely records of the care they provide to their patients to support communication, continuity and decision-making (Box 2); this includes all forms of records documenting information about individual patients and their care and treatment (RCN, 2012).
Box 1. NMC Code on record-keeping
- 10. Keep clear and accurate records relevant to your practice. This includes, but is not limited to, patient records. It includes all records that are relevant to your scope of practice. To achieve this, you must:
- 10.1 Complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event
- 10.2 Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
- 10.3 Complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements
- 10.4 Attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation
- 10.5 Take all steps to make sure that all records are kept securely
- 10.6 Collect, treat and store all data and research findings appropriately
Source: NMC (2015)
Box 2. Delegation of record-keeping
- Record-keeping can be delegated to HCAs, APs and nursing students so that they can document the care they provide
- Record-keeping is an integral part of every intervention and the HCA, AP or student should be assessed as competent in the complete provision of care, which includes record-keeping. Until they are deemed wholly competent in both the activity and its documentation, countersigning should be performed
- As with any delegated activity, the registered nurse needs to ensure that it is in the patient’s best interests for the activity and documentation to be delegated to the HCA, AP or student
- Supervision and a countersignature are required until the HCA, AP or student is deemed competent at the activity and keeping records. The principles of accountability and delegation apply
- Registered nurses should only countersign if they have witnessed the activity or can validate that it took place
- Organisations providing healthcare should supply clear guidance on record keeping for all staff, in line with the principles and guidance in the NMC’s Record keeping guidance
Source: Royal College of Nursing (2012)
Documentation in wound care
A wound assessment must be made and accurately recorded at every dressing change: the size of the wound, its depth, colour and shape, as well as the condition of surrounding skin, should all be documented. This vital information indicates the stage and progress of the wound and is vital to ensure that the next clinician caring for the patient selects an appropriate dressing. If mistakes that are made due to inaccurate, incomplete or omitted records lead to patient harm and legal proceedings, an expert witness would have difficulty supporting any nurse who had not provided clear documentation.
While their assessment follows the same principles as that of other wounds, most pressure ulcers are avoidable, so nursing care is primarily preventative. This involves assessing individual patients’ risk of developing pressure ulcers. Nurses should use a risk-assessment tool to identify patients at increased risk. While there is no robust evidence that the use of these tools decreases the incidence of pressure ulcers (Pancorbo-Hidalgo et al, 2006), if a patient developed a pressure ulcer and legal proceedings resulted, expert witnesses would look for evidence that the risk was assessed, and the use of assessment tools offer that evidence. The expert witness will assess whether the type of care provided matched the level of identified risk.
It is vital to perform the risk assessment every time the patient is assessed. In my experience of expert witness cases relating to patients whose condition deteriorated drastically, many assessments recorded the same level of risk as the previous entry, suggesting that the clinician had not actually assessed but simply ticked boxes.
A wound assessment should include assessment of the patient’s skin. Careful inspection and palpation of the skin can give valuable insights into the patient’s general physical condition, and whether it is improving or worsening (Hess, 2008).
Various assessment tools are available to help with recording a wound’s condition and progress if a local tool is not available. Examples include HEIDI, TIME, TELER (Box 3) and Bates-Jensen. All assist with accurate documentation and nurses should use the one required by local policy or select the one that best suits the needs of the patient.
There are many sophisticated methods for measuring wounds, including cameras that provide 3D images of the wound bed. These probably provide the most accurate measurement but are not always available.
Box 3. The TELER system
Treatment Evaluation by Le Roux’s method (TELER) was validated as a method of collecting observational data of dressing performance by Browne et al (2004). It has two main elements: a method of clinical note-making and a measuring mechanism. The note-making method records the relationship between the care provided and outcomes in terms of clinically significant change.
The goals of treatment and care are negotiated with the individual patient. In addition, patients’ experiences of the impact of the wound and wound-related issues, including symptom management, dressing changes and intrusion on daily living, are recorded in personal statements, which are incorporated into the measuring mechanism.
The TELER system is comprehensive and does not rely on wound measurements, but rather on how the patient reports the changes in the healing wound. The outcomes demonstrate a significant method of audit (Grocott et al, 2005).
The easiest measurement method is linear, also known as the “clock” method. This involves measuring the greatest length, width and depth of the wound, imagining the body as the face of a clock, with the head being 12 o’clock and the feet 6 o’clock.
Determine the wound’s length (direct line from 12 o’clock to 6 o’clock) and width (9 o’clock to 3 o’clock) using a disposable ruler. Readings will never be absolutely accurate due to the variety and irregularity of wound shapes; they can only give an indication of changes.
The measurements should be documented at least weekly in centimetres; if the measurements are taken in exactly the same position each time, the wound progress will be clear. The depth can be assessed using a cotton-tipped bud, which is then placed against the ruler to give the greatest depth measurement.
If using photography to chart the progress of a wound, take at least two photographs at each assessment, one about 10cm from the wound and one that shows the position of the wound on the body.
By tracing wounds onto an acetate grid and counting the squares, nurses can quickly calculate an accurate surface area. Different regions of necrosis, granulation and slough can be marked on the acetate and can provide an excellent comparison tool. When the acetate is placed on the wound it will “fog” up and the wound margins may be difficult to define, but this can be overcome by wiping the acetate with alcohol prior to application. However, care should be taken to ensure the alcohol surface does not touch the wound, as this can be extremely painful for the patient.
The first wound assessment provides the benchmark against which progress can be measured. The second may show the wound has grown as debris is removed (Fletcher, 2011). If the wound is going to heal, there will be a distinct difference in its condition by the third and fourth week.
The type of tissue in a wound can also provide information on its progress towards healing. Treatment aims to encourage the development of granulation tissue; when this goal is reached, the wound will go on to heal. All treatment should therefore be considered with the objective of removing necrotic tissue and any bacteria present within the dead tissue. If bacteria are present, there will be an offensive odour.
Accurate and continuous measurement of wounds, and consistent and clear documentation, are vital to ensure good outcomes for patients. Wounds are far more likely to heal if their progress is monitored and nurses treat them accordingly. Documentation need not be a laborious task, and in any case is a professional and legal requirement; failure to complete documentation can lead to legal proceedings if a patient sustains harm and there is no documentation to demonstrate appropriate care was given.
- Documentation is vital in all aspects of care
- Accurate and timely documentation is a professional duty and a legal requirement
- Registered nurses can delegate documentation to unregistered staff
- Wounds should be assessed and measured at least once a week
- A record should be made every time a dressing is replaced
Also in this series
- Wound management 1: Phases of the wound healing process
- Wound management 2: The principles of holistic wound assessment
- Wound management 3: Assessing and treating wound pain
- Wound management 5: Selecting wound dressings for optimum healing
- Wound management 6: How to address wound healing complications
Austin S (2011) Stay out of court with proper documentation. Nursing; 41: 4, 24-29.
Bates-Jensen BM (2001) Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Annals of International Medicine; 135: 8 (Part 2), 744-751.
Brown A (2015) Wound management 2: the principles of wound assessment. Nursing Times; 111: 46, 14-16
Browne N et al (2004) Woundcare research for appropriate products (WRAP): validation of the TELER method involving users. International Journal of Nursing Studies; 41: 5, 559-71.
Fletcher J (2011) How can I accurately measure a wound and how often should I do this. Nursing Times; 107: 4, 15.
Grocott P et al (2005) Quality of life: assessing the impact and benefits of care to patients with fungating wounds. Wounds; 17: 1, 8-15.
Hess CT (2008) Performing a skin assessment. Advances in Skin and Wound Care: The Journal for Prevention and Healing; 21: 8, 392.
Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.
Pancorbo-Hidalgo PL et al (2006) Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of Advanced Nursing; 54: 94-110.
Royal College of Nursing (2012) Delegating Record-keeping and Countersigning Documentation.