Assessment of the Quality of Nursing Documentation for Postoperative Limb Wound Care in Vietnamese Hospitals: A Multi-Site Cross-Sectional Study

Vollständiger Abstract

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Background Nursing documentation plays an essential role in nursing practice, which contributes to ensuring the continuity of nursing, enhancing communication among the care team, and reflecting the quality of patient care. Inadequate or inaccurate documentation may have a negative effect on patient safety and clinical decision-making. To assess the quality of nursing documentation for postoperative limb wound care based on the situation of compliance with a tool called the Surgical Wound Assessment Tool (SWAT) and identify related factors at nine hospitals in Vietnam in 2025. Methods The study used a descriptive, retrospective, cross-sectional design and was conducted at 9 general and specialized hospitals in Vietnam from May 2025 to September 2025. The sample size included 1,012 patient records related to limb wound care (systematic random sampling) and 286 nurses who directly tended wounds. The data collection instrument is a standardized checklist adapted from SWAT, including 27 clinical items. The quality of documentation is considered “Qualified” when the total score is at least 80%. Descriptive analyses were used to present the results, using Chi-square tests and logistic bivariate models ( p < 0.05). Results The quality of wound care documentation was low, with an overall qualification rate of 30.6%. A discrepancy in the documentation was observed: while the rate of qualification for administrative and surgical items was high, ranging from 85.9% to 88.8%, the key clinical parameters showed low rates, especially those related to surgical sites, sizes, and bases (0%). Regression analyses show that the quality of wound care documentation was associated with certain characteristics of patients ( i.e ., BMI, diabetes, and smoking) and nurses’ characteristics such as educational level, seniority (years of work experience), the number of patients that they tended, and the training on wound care documentation that they attended. Discussion This multi-center study highlights a significant gap between clinical guidelines and actual nursing documentation practice in postoperative wound care. The low qualification rate underscores the urgent need for standardized training programs and organizational support. In addition, the findings suggest that enhancing individual nursing competencies and streamlining documentation tools could effectively improve patient safety and the continuity of surgical care in the Vietnamese hospital context. Conclusion The quality of nursing documentation for postoperative limb wound care conducted by nurses at nine studied hospitals was poor, especially when it came to assessment of clinical characteristics of wounds. Related factors included patients’ medical conditions and nurses’ professional factors, especially professional training and workload. The standardization of forms for documentation using SWAT, enhancing training, and reducing the number of patients in need of care would contribute to improving the quality of documentation.