Authors (including presenting author) :
Chung WY(1), Yum WK(1), Lai YK(1), Chan YK(1), Lo KY(1), Wong TW(1), Chui ST(1)
Affiliation :
(1) Department of Surgery, Prince of Wales Hospital
Introduction :
All burn patients in Burns Centre at Prince of Wales Hospital receive different levels of wound management throughout the hospital stay. The definitive treatment plan is depending on the wound condition and its progress. So, a comprehensive wound assessment and accurate documentation are vital for making medical decisions. However, few problems on these areas had been identified. Firstly, the current practice of wound documentation was inconsistent. Secondly, the components of wound documentation varied among staff. Thirdly, the current burn wound chart didn’t meet the clinical needs. In order to fill the gap, a new standardized burn wound assessment and management form and a user guide had been developed.
Objectives :
1. To standardize the components and format of burn wound documentation 2. To simplify the documentation of burn wound conditions 3. To raise the accuracy of burn wound handover
Methodology :
Literature review was conducted on burn wound assessment, management, documentation and development of a wound assessment form. Besides, current practice on wound documentation and mode of handover were reviewed. Then a set of burn wound assessment and management form and its user guideline had been drafted and sent for validity and reliability test. After that, 2 briefing sessions were organized for burn care nurses to introduce the new form and its user guide. Subsequently, a 2-week pilot period of the new form was implemented on 7 patients. Colleagues were required to record burn wound conditions both in progress note (usual practice) as well as new wound form, for comparison of consistency and compliancy. Furthermore, staff satisfaction survey on the usage of new form was collected.
Result & Outcome :
Comparing the two types of wound documentation, the new wound form was more comprehensive and accurate in terms of wound location, description and progress. All burn care nurses in Burns Centre had participated in the pilot period. The response rate of staff satisfaction survey was 100%. They all agreed the new wound assessment form was easy to use, time saving and consistency enhancing. It also fully demonstrated the wound conditions and facilitated handover. Hence, replacement of the old wound chart should be considered. The results demonstrated positive impacts of the new form in Burns Centre. It filled the discrepancy of current practice in burn wound documentation.
