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Updated: Jun 3, 2026
09:06
Assessment of Acute Wound Healing using the Dorsal Subcutaneous Polyvinyl Alcohol Sponge Implantation and Excisional Tail Skin Wound Models.
Published on: March 25, 2020
Improving Wound Assessment Documentation Using a Structured Scoring Tool: A Closed-Loop Quality Improvement Project
Rayan Hamza Mohamed Ahmedalgabri1, Nada Abdelnaser Ahmed Alshorbagy2, Amr Elbanna Mohammed Aly2
1Dermatology, Regional Dermatology Training Centre, Moshi, TZA.
Cureus
|June 2, 2026
Summary
Implementing a structured wound assessment tool significantly improved documentation completeness, enhancing patient safety. This quality improvement project demonstrated better recording of wound exudate, tissue exposure, and infection risk.
Area of Science:
- Healthcare Quality Improvement
- Clinical Documentation Standards
- Patient Safety in Wound Care
Background:
- Incomplete wound assessment documentation poses risks to clinical decision-making, care continuity, and patient safety.
- Structured documentation tools aim to standardize wound assessment and reduce variability in practice.
- A quality improvement project was initiated to assess the impact of a structured tool on documentation completeness.
Purpose of the Study:
- To evaluate the effectiveness of a structured wound assessment scoring tool in improving documentation completeness.
- To identify specific areas of wound assessment documentation that benefit from standardization.
- To assess the impact on patient safety through enhanced documentation.
Main Methods:
- A closed-loop quality improvement project utilized two audit cycles.
- Fifty wound dressing records were reviewed in a baseline assessment (Cycle 1).
- A structured wound assessment scoring tool (WOUND-DRESS) was implemented with staff education, followed by a second audit (Cycle 2).
Main Results:
- Significant improvements were noted in recording wound exudate (50% to 100%), depth/tissue exposure (28% to 100%), and infection risk (16% to 100%).
- Calculation of total wound score improved from 6% to 100%, and documentation of actions taken increased from 42% to 100%.
- Documentation of dressing type did not show significant improvement.
Conclusions:
- Implementing a structured wound assessment scoring tool led to substantial improvements in documentation completeness, especially in critical safety domains.
- Structured tools, combined with education and audit feedback, enhance wound documentation standardization and patient safety.
- Ongoing monitoring is crucial for sustaining improvements in wound care documentation.
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