Wound documentation
Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance.
How was this assessed?
Response
Accepted
Response
AcceptedSection 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code requires nurses to maintain clear and accurate records, completing them as soon as possible after an event and identifying any risks or problems and the steps taken to deal with them. The GMC similarly requires doctors to keep clear, accurate, and legible records of concerns and actions. Additionally, Section 4.1 notes that Healthcare Improvement Scotland published a Best Practice Statement - Prevention and Management of Pressure Ulcers in 2009, which would inform best practice guidance for documentation.
Published Evidence
Published assessments of implementation progress from inspectorates, select committees, official progress reports, and other sources. Check the source type badge to see whether each assessment is independent or government self-reported.
Excellence in Care CAIR Dashboard monitors wound documentation standards as part of fundamentals of care metrics. National wound care guidance available.
View detailed findings
Wound documentation addressed through national nursing quality framework.