Wound Care Information Standard

The standard is intended to support the aims of the National Wound Care Strategy Programme (NWCSP) to:

• Reduce patient suffering
• Improve healing rates
• Prevent wounds occurring and recurring
• Use clinical time and other health and care resources in the most effective way

It is based on professional guidance, the relevant NICE guideline, evidence review, and extensive consultation with health professionals, people, and carers.

The standard covers the assessment, diagnosis, treatment, ongoing care and prevention of the wounds across all health and care settings for three areas of wound care;

• Lower limb (leg and foot) wounds
• Pressure ulcers
• Surgical wound complications
• The standard is UK wide and is for adults and children.

• Wound types not specified above, including those caused by external factors such as new trauma and burns (although it may work for these).
• Management of arterial and peripheral vascular disease. While leg wounds often result from peripheral venous or arterial disease, prevention and management of vascular disease is beyond the scope of this standard.
• Management of Lymphoedema. While leg wounds may result from lower limb lymphoedema, management of lymphoedema is beyond the scope of this standard.

With the exception of surgical wounds, wound care normally starts with a baseline assessment of the wound and the person. The wound assessment and treatment section of this standard allows for recording details of the “contact with professionals” for each contact. This is likely to be followed by a “baseline assessment”, “clinical observations”, and initial treatments. The baseline assessment is then likely to be used to develop a treatment plan through discussion with the individual of their “About Me” information, gathering their “Person preferences” and considering the relevant treatments.

The treatment plan would be added to their “personalised care and support plan” using the “care and support plan” section for their needs, goals and actions and if needed an “additional support plan” for the details of the medical treatment. A “contingency plan” (also known as an escalation plan) can also be created if appropriate.

It is recognised that for surgical wounds, the treatment plan may be developed pre-surgery, and the assessment and treatment will only apply if wound complications occur post-surgery.

All further contacts with professionals would then be recorded in a similar way along with assessments, observations and treatments as deemed professionally appropriate. The standard supports professional guidance by allowing consistent information to be recorded with the potential for prompts for the information recorded in assessments, observations and treatments.

The supported self-care (self-management) section enables the recording of any self-care that the person with a wound may do, and for the person to record documents or images which can be uploaded to a clinical system or patient record.

All elements in the information standard are defined as either Mandatory, Required or Optional. Very few elements are mandatory, many are required and these only need to be entered when they are collected or known, and can be left blank when they are not appropriate for that occasion.

• Mandatory – The information must be recorded.
• Required – If it exists, the information must be recorded.
• Optional – Local decision is made as to whether the information is recorded.

The information standard defines the data that should be recorded to support care professionals in their delivery of high quality care. IT system suppliers are expected to build or customise their clinical systems to allow the recording of this data. Systems will be a mix of specialist wound care management systems and more general electronic patient record systems. Care professionals need to be aware of the standard but do not need to have a complete, in depth understanding of the detail of the standard’s information model. Care professionals should be reassured that their system has implemented and operates in accordance with the information standard. It is recommended that those responsible for clinical systems check if their suppliers have implemented the standard.