Wound Care Audit Form

DEFINITIONS:

•    Healing Wound: acute or chronic wound healing in a predictable course

•    Non-healable Wound: (malignant/ palliative) - Unable to remove causes impeding healing, supportive care provided

•    Non-healing Wound: wound has potential to heal, causes impeding healing have not yet been removed


To complete audit:

-   Audit all wounds, with max 5 per unit/home

-   Include all types of wounds (new, existing, surgical, pressure, etc)

-   Complete and submit this form for each wound being audited    

-   Complete audit quarterly (any time within the quarter)  

- Make note on chart (ie: write quarter audited) in order to avoid auditing same chart twice in same quarter   

-   Complete or assign corrective actions ASAP following audit            

Note: can't save & return to this form, must complete all fields and submit for each wound

Select your Integrated Service Area*
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Quarter Audited*

Indicate if there is documented evidence of the following:

1. Patient received a comprehensive wound assessment on admission, or upon identification of wound.*

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure].

Also see: Skin & Wound Care intranet page

2. Wound care goal.*

ie. healing, non-healable (palliative/maintenance), non-healing

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure]-Section B for wound care goal examples.

3. Individualized Established Plan of Care based on an assessment of the wound, and patient's goals.*

(documented care plan)

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure]-Section D for plan of care examples

4. A prescriber's order for wound care & management.*

Note: It is advised that general wounds are ordered as such "wound care as per best practice recommendations"

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure]- Appendix G: Wound Care and Treatment Order Requirements

5. Multidisciplinary health professional collaboration (ie. referral or consult).*

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure] –Section C: Assesmble the team and Section E: Referrals and Consults / CS-CDCS-0015 Consults – Acute Care

6. Use of SHA-approved Wound Record* (*has SHA assigned number, ie. SHA-XXXX) OR the NISS Wound Record OR BWAT at EACH wound assessment/dressing change.*

Note: Former RHA wound records are not acceptable unless approved by SHA (*as above)

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure] – section G: Documentation and Appendix D: Wound Record Documentation (descriptors)


If using NISS #WR145.1-User manuals are available on the NISS webpage of the SHA Intranet (links available after submitting this audit)

7. Separate wound record for EACH wound.*

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure] – section G Documentation and Appendix D: Wound Record Documentation (descriptors)


If using NISS #WR145.1-User manuals are available on the NISS webpage of the SHA Intranet (links available after submitting this audit)

8. Patient / family received information and education on skin and wound self-care.*

Select corrective action(s) you and/or team will take:

Refer to: Skin and Wound Care and/or Patient Information and Education Resources (PIER) on public webpage

Procedure: CS-CP-0025 Skin and Wound Assessment and Management - Section F: Evaluate Outcomes

9. The patient's skin and wound care information is shared at all transition points of care.*

(i.e. Home Care patients admitted to LTC and Acute Care)

Select corrective action(s) you and/or team will take:

Refer to:

CS-CP-0025 Skin and Wound Assessment and Management [procedure] – Requirements for Care Transitions

CS-CDCS-0064 Transfer of Patient Facility to Facility

CS-CDCS-0021 Discharge or Episodic Care Separation

CS-CDCS-0004 Admission/Move-In Documentation

10. Patient has ongoing wound evaluation.*

(ie. documented interventions, wound treatment plan changes, physician updates, wound measurements)

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure]

11. Expected rate of wound healing, including the change in surface area (%)*

Are further interventions, referrals or consults needed? If so, select corrective action(s) you and/or team will take:

Refer to: CS-CP-0025 Skin and Wound Assessment and Management [procedure] – Section D.2

SHA approved wound record such as NISS #WR145.1

Wound Assessment Tool – Bates-Jensen Wound Assessment Tool (BWAT) on chart

12. Photos taken of wound (at minimum) on admission, change of status, and at re-assessments, and added to chart.*

Note: For digital images, PRINT & place in paper chart; OR save in electronic health record

Select corrective action(s) you and/or team will take:

Refer to: CS-CP-0026 Clinical Photography and CS-CDCS-0048 Photographs and Video

13. Skin assessment (for breakdown, including pressure injury risk) as per policy requirements.*

(ie. Skin and Bath Temp Form where applicable)

Select corrective action(s) you &/or team will take:

Refer to: SHA-0302 Skin Inspection and Bath Water Temperature Checks;

CS-CP-0025 Skin and Wound Assessment and Management [procedure] – Section A: Assessment / Reassessment

You're done! Go ahead and submit.

Remember to check 'Send me a copy of my responses' to send Corrective Actions to you/your manager.

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