การพัฒนาและการใช้แบบบันทึกการจัดการบาดแผลสำหรับผู้บาดเจ็บ ในแผนกฉุกเฉิน

Abstract

A wound management record is an important tool to facilitate continuous wound management for traumatic persons. This developmental research aimed to develop a Wound Management Record Form for trauma patients in an emergency department and study the completeness of the wound management record before and after using the record form. The National Health and Medical Research Council’s Guide to the Development, Implementation and Evaluation of Clinical Practice Guideline was used as the study framework (NHMRC, 1999). The participants were the Record Form Development Team and 20 emergency department nurses. The research instruments included the developed Wound Management Record Form, the Feasibility of Wound Management Record Form Questionnaire and the Completeness of Wound Management Record Form. The results revealed that: 1. The characteristics of the Wound Management Record Form were a 1-page paper form, including a checklist, abbreviation for recording, full-body anatomical picture for location recording and space for information filling. There were 5 components including wound assessment, wound cleansing, wound closure and dressing, antibiotics and vaccinations, and follow-up. 2. Before implementing the Wound Management Record Form, there was no complete record of any component. After implementing the Wound Management Record Form, there were 98.48 percent complete records on each of the 5 components. The developed Wound Management Record Form is clinically appropriate. Emergency departments can use the Record Form for further quality improvement in wound management among traumatic persons