Improving Wound Assessment Documentation Using a Structured Scoring Tool: A Closed-Loop Quality Improvement Project...

Background Incomplete wound assessment documentation can compromise clinical decision-making, continuity of care, and patient safety. Structured documentation tools have been proposed to standardize wound assessment practices and reduce variability. This quality improvement project evaluated the impact of implementing a structured wound assessment scoring tool on documentation completeness at Al Managil Teaching Hospital. Methods A closed-loop quality improvement project was conducted using two audit cycles. Fifty wound dressing records were reviewed during a two-week baseline assessment (Cycle 1). Following analysis of deficiencies, a structured wound assessment scoring tool (WOUND-DRESS) was introduced alongside focused staff education and reinforcement over a two-month implementation period. A second audit cycle was conducted over three months, reviewing 50 additional records. Compliance with predefined documentation standards was compared between cycles using chi-square testing. Results Significant improvements were observed across most documentation domains. Recording of wound exudate increased from 25/50 (50%) to 50/50 (100%) (p < 0.001), depth and tissue exposure from 14/50 (28%) to 50/50 (100%) (p < 0.001), and infection risk from 8/50 (16%) to 50/50 (100%) (p < 0.001). Calculation of total wound score improved from 3/50 (6%) to 50/50 (100%) (p < 0.001), and documentation of action taken increased from 21/50 (42%) to 50/50 (100%) (p < 0.001). Administrative variables also improved, although documentation of dressing type did not demonstrate significant improvement. Conclusion Implementation of a structured wound assessment scoring tool was associated with substantial improvements in documentation completeness, particularly in safety-critical assessment domains. Structured tools combined with targeted education and audit feedback can enhance standardization of wound documentation and support patient safety. Ongoing monitoring is required to sustain these improvements.