Development of wound management record form for traumatic persons in Emergency Department, Maharaj Nakorn Chiang Mai Hospital

Abstract

Objectives To develop a wound management record form for traumatic patients in the emergency department and to explore the feasibility of using the form to record wound management of traumatic patients in an emergency department. Methods This developmental study used the National Health and Medical Research Council’s Guide to the Development of Clinical Practice Guideline (1999) as the research framework for development of the record form. The form was tested for feasibility by 20 emergency nurses who recorded wound management for 70 trauma patients who also completed a Wound Management Record Form Feasibility Questionnaire. The data were analyzed using descriptive statistics. Results The Wound Management Record Form developed was a one-page paper form which includes a checklist, standard abbreviations, a full-body anatomical picture for recording location, and space for additional information. The form includes five components: wound assessment, wound cleansing, wound closure and dressing, antibiotics and vaccination, and follow-up. Evaluation of use of the form found the completeness of components 1-5 to be 88.57, 82.86, 90.00, 81.43, and 82.86 percent, respectively. The majority of participating nurses either agreed or strongly agreed that the form was easy and convenient, precise and valid, appropriate as a wound management record for the emergency department, and saved time in recording information. The majority felt the form to be effective and feasible for use in an emergency department. Conclusion The Developed Wound Management Record Form is both appropriate and feasible for use in emergency departments.