ASSESSMENT OF NURSING CARE RECORD DOCUMENTATION FOR PATIENTS WITH WOUNDS AT 19-8 HOSPITAL, MINISTRY OF PUBLIC SECURITY, IN 2025

Objective: To describe the current status of wound care documentation among hospitalized patients at 19-8 Hospital in 2025. Materials and Methods: A cross-sectional, retrospective descriptive study was conducted on 219 inpatient medical records from surgical departments between February and August 2025. Data were collected using a pre-designed checklist evaluating the quality of nursing documentation for patients with wounds. Results: Over 95% of medical records contained documentation of subjective and objective symptoms. However, 14.2% of nursing care and monitoring forms did not record the level of care; only 4.6% of records included assessments of paraclinical (laboratory or imaging) results; 63.5% lacked fall risk assessment, and 13.2% did not assess pressure ulcer risk. More than 90% of nursing interventions were adequately documented in the medical records. Conclusions: The proportion of nursing care records meeting quality standards was 75.3%. It is necessary to strengthen training and supervision, focusing on areas with lower compliance rates, such as documentation of abnormal paraclinical indicators and nursing diagnoses.