Documentation of wounds in emergency departments through a forensic lens

Nurses document wounds to direct and evaluate the care. People admitted to emergency departments with wounds should be regarded as potential forensic patients, requiring meticulous documentation for evidence purposes.

To explore the documentation of wounds in emergency departments through a forensic lens and compare it between different levels of emergency departments.

In this descriptive retrospective study, we randomly sampled 515 paper-based medical files of patients who sustained wounds admitted to three selected emergency departments. The files were analysed using a structured data collection tool the data were descriptively analysed.

All files included information on the type of wound (100%) and the site of the wound (100%) with most files including the mechanisms of injury (98.6%). Few files included information on blood loss (18.1%) and the size of the wound (15%). Only one file included information on the contents of the wound. No files included information on the wound's shape and the surrounding skin's condition.

Wounds were poorly documented in emergency departments, irrespective of the level of care. Nurses in emergency departments should have strict guidelines for documenting wounds since accurate documentation protects patients' human rights and protects nurses.