RESUMO
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.