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.
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that wound or pressure damage is documented in accordance with best practice is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
How was this evidence gathered?
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 progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates 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.