Documentation of wounds in emergency departments through a forensic lens.
Clinical forensics
Emergency department
Emergency nursing, forensic nursing
Injuries
Wound description
Journal
International emergency nursing
ISSN: 1878-013X
Titre abrégé: Int Emerg Nurs
Pays: England
ID NLM: 101472191
Informations de publication
Date de publication:
09 2023
09 2023
Historique:
received:
28
09
2022
revised:
06
07
2023
accepted:
12
08
2023
medline:
2
10
2023
pubmed:
16
9
2023
entrez:
15
9
2023
Statut:
ppublish
Résumé
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.
Sections du résumé
BACKGROUND
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.
AIM
To explore the documentation of wounds in emergency departments through a forensic lens and compare it between different levels of emergency departments.
METHODS
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.
RESULTS
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.
CONCLUSION
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.
Identifiants
pubmed: 37714057
pii: S1755-599X(23)00086-1
doi: 10.1016/j.ienj.2023.101347
pii:
doi:
Types de publication
Journal Article
Langues
eng
Pagination
101347Informations de copyright
Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.
Déclaration de conflit d'intérêts
Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.