Anneli Ensio

Developing the standardized wound care documentation model: a Delphi study to improve the quality of patient care documentation.

OBJECTIVE: The aim of this study was to validate a set of previously developed criteria for wound care documentation and to use the validated criteria as a framework for developing a wound care documentation model. The Skin Integrity component of the Finnish Care Classification, the Finnish Classification of Nursing Diagnosis, and the Finnish Classification of Nursing Interventions serve as the basis for the wound care documentation model. SUBJECTS AND SETTING: Finnish wound care specialists, mainly nurses, from different Finnish hospitals, and from the Finnish Wound Care Society having on average 18 years of experience in wound management. Data were collected using electronic survey technology. METHODS: A Delphi technique was used to develop and validate the documentation system. RESULTS: The final model consists of 7 main categories and 25 subcategories of the Skin Integrity component of the Finnish Classification of Nursing Diagnosis and 5 main categories and 25 subcategories of the Skin Integrity component of the Finnish Classification of Nursing Intervention. Based on the results of the Delphi survey, consensus was reached on all elements of the wound care documentation model. CONCLUSION: The Delphi process was used to develop a wound care documentation model for use in an electronic record to promote systematic documentation of both wound assessment and wound care. Future research should address the utility of this documentation model for nurses with expertise in wound care and generalist nurses.