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

2.1. Study Design

With a descriptive, cross-sectional design, this retrospective study was conducted from February 27, 2025, to December 31, 2025, at the Departments of Surgery-Trauma in nine hospitals in Vietnam. The study subjects included 1.012 nursing records for patients who experienced limb surgeries and had their wound care documented during their hospital stay: 1) Hospital A - a hospital under Ministry of Public Security, based in Hanoi (101 records); 2) Hospital B under the Ministry of Agriculture and Rural Development, also based in Hanoi (96 records); 3) Hospital C under Hanoi Department of Health (148 records); 4) Hospital D under Bac Ninh Provincial Department of Health (131 records); 5) Hospital E under Quang Ninh Provincial Department of Health (63 records); 6) Hospital F under the State Capital Investment Corporation (SCIC), located in Hanoi (30 records); 7) Hospital G under Hai Phong Provincial Department of Health (77 records); 8) Hospital H under Vietnamese Ministry of Health, located in Hanoi (260 records); and 9) Hospital I under Vietnamese Ministry of Health, located in Ho Chi Minh city (106 records). We also studied 286 nurses who directly provided care and documented nursing records for such patients.

2.2. Sampling Methods

2.3. Inclusion Criteria

2.4. Exclusion Criteria

2.5. Subjects

2.6. Study Instrument

For the study purposes, we developed the study instrument using Circular No. 32/2023/TT-BYT [10] and clinical guidelines for acute and surgical wound management [10], and the Surgical Wound Assessment Tool (SWAT) [6]. The third reference serves as a tool for assessing how completely and accurately surgical wounds are documented in Vietnam [6].

The tool comprises three sections: (1) Patient demographics and surgical characteristics: including gender, age, surgical procedure performed, duration of surgery, length of hospital stay, health insurance status, post-operative wound classification, emergency surgery status, and preoperative prophylactic antibiotic use. (2) Characteristics of nursing staff and nursing documentation: including gender, age, educational level, years of experience, training in medical record documentation, training in wound care, and the average number of patients cared for per nurse per day. (3) Factors related to the patient, comorbidities, and surgery surgical wound assessment, divided into two groups: This section consists of two groups with 27 items: (1) factors related to patients and comorbidities, and factors related to surgery (13 items, maximal total score: 39); and (2) assessment of the clinical characteristics of surgical wounds (14 item, maximal total score: 42). The instrument was validated by five surgical nursing experts. A pilot study on 30 nursing records showed high inter-rater reliability (Kappa > 0.8) and high internal consistency (Cronbach’s alpha = 0.949).

2.7. Data Collection Method

Data were collected by data collectors with thorough training on SWAT.

Retrospective: Reviewing and assessing nursing documentation forms in the medical records based on the checklist.

Survey: Questionnaire forms were directly provided to nurses after the study purposes were explained to them, and they provided their consent.

2.8. Evaluation Methods

Each item/the quality of the nursing document was assessed using a 3-point Likert scale: Did not document (1 point), documented insufficiently (2 points), and documented fully (3 points). The total score varied from 27 points to 81 points. A medical record was rated as “adequate” or “fully qualified” when the total score was at least 80% of the maximal total score of each section. The total score for the section of surgical wound assessment was ≥ 64.8 points.

This 80% threshold was determined with the consensus of a panel of five experienced surgical nursing experts to reflect high clinical standards. Furthermore, the Ministry of Health’s criterion C6.3 for assessing hospital quality was used to develop the tool for evaluating the quality of documentation [11] and was officially used in prior studies on assessment of nursing documentation in Vietnam [12]. This strict threshold reflects the necessary level of documentation to ensure patient safety and the continuity of wound care in the post-operative context.

2.9. Statistical Analysis

After the collection period, data were entered and analyzed using SPSS version 20.0. Data were presented descriptively as frequencies, percentages, and means ± standard deviations (SD). Chi-square tests were employed to compare between groups, and logistic regression analyses were performed to identify factors related to the quality of nursing documentation. The results were displayed as odds ratios (ORs) and 95% confidence intervals (CIs), with a significance level of p < 0.05.

2.10. Ethical Considerations

The current study received approval from the Ethics Committee of Hanoi University of Public Health under the Decision No. 261/2025/YTCC-HD3 dated September 22, 2025. It complies with the STROBE reporting guidelines, with all information that identifies patients and nurses being coded, kept strictly confidential, and only used for study purposes. Nurses’ right to refuse to participate in the study was respected, and their refusal did not affect their jobs.

3.1. Patients’ Clinical Characteristics and Nursing Workload

The study population included 1,012 patients and 286 nurses. Overall, male patients outnumbered female patients (63.1% vs. 36.9%); most patients were in the working-age group (18-29 years; 29.9%); and health insurance coverage was overwhelmingly high (93.8%). As for nurses, most held a professional qualification (College or University degree); however, just over one-fifth had attended specialized training courses/classes on medical record documentation after the applicable regulations were in place. Nurses also faced heavy clinical workloads, each serving 10 patients per day, on average (see Tables 1 and 2 in the Appendix, respectively).

3.2. Documentation Quality

Of all the 1012 nursing documentations, 702 were rated as not qualified (69.4%), compared to 310 as qualified (30.6%). Only three out of nine hospitals had qualified nursing documentation. Hospital H had the highest rate (228 qualified nursing records; 87.7%), followed by Hospital A (78; 77.2%) and Hospital F (4; 13.3%). Six hospitals with unqualified nursing records included Hospitals B, C, D, E, G, and I.

The two most frequently documented patient factors were trauma (74.3%) and BMI (62.3%), with diabetes and smoking as the two least documented (46.2% and 44.0%, respectively). Surgical factors with the highest rates of accurate documentation, in descending order, were wound type (90.8%), duration (88.2%), and preoperative antibiotic prophylaxis (68.3%). In terms of clinical wound assessment, the most frequently recorded factors included the nurse’s name (62.2%) and pain scale (47.1%), compared to the lowest rates of 0% observed for surgical site and incision size. The rate of non-documentation ranged from 8.7% to 62.0%.

The rate of documenting wound assessments after 10 days of surgery experienced a consistent decrease. Basic factors such as surgical site and dressing were frequently recorded right after the surgery but declined over time. Clinical factors, for example, wound size and edge, were two among factors with consistently low rates of documentation, which reduced after surgery. Of note, pain assessments were most frequently recorded but not adequately or consistently.

3.3. Factors Influencing the Quality of Nursing Documentation

According to statistical analysis, factors having a negative association with the quality of documentation included having a BMI ≥ 23kg/m² and having a history of smoking or steroid use. However, diabetes was found to have a positive association with the quality of documentation (p < 0.001). Unlike type of surgery, duration of surgery, and type of surgical wound, factors such as chemotherapy, immunodeficiency, and risk of malnutrition did not show a statistically significant association with the quality of documentation.

Nurses’ educational level, years of experience, daily patient load, and formal training under Circular No. 32 were statistically significantly associated with the quality of documentation (p < 0.05). For example, serving 10 or more patients per day and the lack of training opportunities under Circular No. 32 compromised the quality of documentation (OR = 0.336;; 95% CI: 0.204-0.552 and OR = 10.581; 95% CI: 4.796-23.345, respectively; p < 0.001). Factors with no significant association comprised age and gender, and with all nurses having attended training courses on wound care, it was not possible to assess the impact of training.

4.1. The Quality of Nurses’ Documentation of Wound Care after Limb Surgery

The current study demonstrated the poor quality of nurses’ documentation of nursing records for patients with wounds after limb surgeries, with a low overall rate of qualified documentation (30.6%) (Table 3). This result is consistent with recent evidence from other studies conducted worldwide. According to Abura et al. [13], despite nurses’ awareness of how important documentation of wound care is, their actual practice did not meet professional standards. This indicates that translating nursing knowledge into consistent documentation performance remains a persistent challenge, especially in assessing surgical wounds and recording patient-related surgical factors. This consisted of surgical wound assessment aspects, as well as patient-related and surgical factors. This result is aligned with the overview and prior studies, which showed that nurses had not fully met the requirements of documentation in terms of completeness, consistency, and the likelihood of support in the decision-making process [1-3, 14]. This is consistent with previous studies reporting incomplete and inconsistent nursing documentation, which may compromise continuity and safety of patient care [15]. The rate of qualified documentation in our present study may be related to some factors. First, the study used a threshold of 80% for the assessment, which is a strict criterion for documentation of details about wound characteristics. Besides, Circular No. 32/2023/TT-BYT has been in effect since January 1, 2024; hence, nurses seem not to have entirely adapted themselves to the emerging requirements of documentation practices. Our study suggests that there is a need for standardized training due to the fact that the current quality of documentation has not met expectations. Our study result is consistent with the findings of Tasew et al. (2019) [16], indicating that ineffective documentation of wound care may be due to a lack of in-service training on nursing standards. In addition, the latter study emphasized the importance of periodic professional training and establishment of operational standards. Our study findings inform the specialized SWAT training for nurses in 2026. Key wound assessment factors have not been paid sufficient attention, which indicates the need for providing standardized training for nurses to address this issue. These findings were also mentioned by Do [6] and Gillespie [8], who linked poor documentation to insufficient training and inconsistent skills. Besides, the link between incomplete records and heavy workload confirms other research showing how workplace pressures lower documentation quality [1].

In our study, male patients outnumbered the female ones; working-age and middle-aged patients made up an overwhelming percentage of all (Table 1). Those experiencing emergency surgeries and having prolonged hospital stays accounted for relatively high rates (Table 1). This indicated that the monitoring and documentation of surgical wounds is greatly needed. However, due to the burden of overloaded work and the high pressure of patient care, especially in emergencies, the documentation seemed to be simplified. Research showed that incomplete documentation was not due to nurses’ lack of knowledge but was associated with documentation forms that were not in line with clinical procedures. This led nurses to prioritize direct patient care over completing the documentation tasks [5, 6, 14].

Although most nurses graduated from colleges and universities (Table 2), there was a low rate of those who had received specialized or updated training on documentation and wound care. Our study results also suggested that the training on medical record documentation in accordance with Circular No. 32 was significantly associated with the quality of documentation. This finding suggests continuing education improves documentation quality more than formal qualifications alone. The rate of qualified documentation reported by nurses without such training was lower than that of those who used to receive such training (OR=10.581; 95% CI: 4.796-23.345, p<0.001). This result is similar to that pointed out by a study in Jamaica and Ethiopia, in which training courses and instrument standardization were regarded as key factors determining the quality of nursing documentation [3, 5, 17]. This may mean that educational levels alone, but accompanied by ongoing training and clinical practice supervision, were not enough to ensure the quality of documentation.

The study’s results revealed a reality of great concern: only 30.6% of the nursing records met the overall documentation quality standards (Table 3). This rate is markedly lower than that reported in a recent Vietnamese study under Circular No. 32/2023/TT-BYT (88.8%). A possible explanation for this is that different assessment approaches were used. More precisely, unlike previous studies which focused primarily on administrative aspects, ours paid attention to clinical ones. Poor clinical documentation does not necessarily reflect low professional competence. According to a previous study of ours, nurses demonstrated high knowledge scores in terms of care planning [18]; however, the reality of nursing documentation in this current study pointed out a large difference between knowledge and practice. This reflects a common situation, which is that the competency of clinical practice sometimes does not match what was recorded in nursing records. This gap might be due to time pressures in departments of surgery or the fact that nurses were not fully aware that nursing records themselves serve as their professional and legal “voice,” as specified in a study by Do Thi Thu Hien (2021) [19]. This 30.6% (Table 3) reflected the huge gap between current regulations and clinical practices in Vietnam. This result is aligned with that in the study by Do Thi Thu Hien et al. (2020) in certain provincial hospitals, where nursing documentation was described as “not complete and inconsistent” [19]. Although high rates of qualified documentation were reported by de Groot K (2022) [1], this difference needs to be investigated from an in-depth methodological perspective. Our current study used an integrated instrument based on SWAT and standardized in Vietnamese by Do Thi Thu Hien et al. (2022) [6]. SWAT not only requires nurses to document whether or not care is present, but provide detailed description of the biological characteristics of the wound using 27 strict items. The application of the threshold of ≥ 80% (64.8 points) as the rate at which the documentation is considered qualified was based on the consensus from experts and the MOH’s Criteria C7.1 [11], providing regulations for nursing documentation [10]. This accidentally “exposed” the gap in documentation easily overlooked by conventional documentation forms. This confirms that although clinical standards in Vietnam have improved to meet international standards, documentation practices still face a substantial gap that must be bridged.

An important finding is the discrepancies between the rates of qualified documentation of surgical information (surgical wound types 88.8%, duration of surgery 85.9%) and those of biological characteristics of surgical wounds. Much lower rates were observed for key parameters such as surgical margin (19.6%), odor (25.5%), exudate (26.6%), and especially surgical incision site/size (0%) (Table 4). These results matched those reported by Do HTT et al. (2021), noting zero percent for site, size, and surgical wound bed within five days of surgery [19].

The study analyzed data for each day after surgery and found that the overall rate of documenting clinical wound characteristics remained low throughout the 10-day follow-up period (Table 5). We found that the rates declined over that period, although it is considered a critical period for early detection of post-operative complications. Most assessment items, including wound edges, signs of infection, discharge, haematoma, or surgical wound odor, were documented in only 15-30% of nursing records on most post-operative days. Notably, surgical wound size, a vital parameter for monitoring wound progression over time, was almost entirely unavailable from documentation on the first day after surgery. This suggests that nurses tend to “clericalize” documentation, prioritizing easily quantifiable data, for example, body temperature (100%), over clinical descriptions that are sensory-based and prognostic in nature.

The shortages found in documentation are not necessarily due to a lack of knowledge but are closely associated with nurses’ workload pressure and their awareness of the importance of nursing records. According to a qualitative study by Do HTT et al. (2021), nurses often consider documentation as “not important” compared to direct interventions [19]. Given the heavy workload and pressure induced by emergency cases (which accounted for a high percentage in our study), nurses tended to prioritize direct care interventions to ensure patient safety rather than spending time filling out forms that are poorly integrated with clinical workflows [5, 6, 14]. Our study results confirmed this. The number of patients cared for by a nurse during a day was significantly associated with the quality of nursing documentation. In particular, nurses who cared for≥10 patients/day were less likely to provide qualified documentation than those who cared for <10 patients/day (OR=0.336; 95% CI: 0.204-0.552). In line with previous studies, ours confirmed heavy workload as a key factor compromising the quality of nursing documentation, indicating that surgical units need proper staffing. This indicated that as the workload increased, the time spent completing clinical records decreased. The quality of nursing documentation is legally required and reflects professional practice. According to Moldskred et al. (2021), regularly using standard checklists to review nursing notes helps identify missing information and improves electronic records [20]. This is also consistent with that of Kim De Groot [1], demonstrating a universal situation in which nurses consider documentation as an administrative burden, separated from the actual care provision.

The 27 SWAT items are essential for limb surgical wounds for the following reasons. The study’s sample size comprised mostly male patients with trauma (52.2%) (Table 1) [19]. Combined with high rates of diabetes (65.5%) and smoking (28.2%) (Table 6), the monitoring of surgical wounds is greatly needed [1, 2]. In limb surgery, a detailed assessment of “wound edges” and the “surgical wound bed” not only provides morphological description but acts as a prognosis for tissue viability. For high-risk groups, such as diabetic patients, a fibrotic wound edge is an early sign of localized ischemia. If nurses overlook this type of sign, the risk of silent necrosis may result in osteomyelitis, and ultimately, limb amputation is unavoidable. Failure to comprehensively document these systemic factors is a situation also observed in the Czech Republic [21].

The study found a low rate of qualified documentation, which is similar to those in other studies, for example, Seidu et al. (2021) [22]. That study reported that most nurses had adequate knowledge and positive attitudes, but only nearly three-quarters practiced adequate nursing documentation, with workload and lack of motivation as the most important barriers to their practice [23]. Standard tools like SWAT help apply knowledge consistently. Alkan (2026) showed structured tools improve care without extra burden; Ausserhofer et al. (2025) confirmed time pressure harms documentation [24]. These results confirmed that documentation quality depends heavily on workplace culture. Nurses often focused on care over records, so management must shift from compliance-only recording to building solid evidence of care (Alkan, 2026; Ausserhofer et al., 2025) [24, 25]. These similarities reinforced the hypothesis that nursing documentation is largely governed by organizational culture. That nurses prioritize direct interventions, including injections and wound dressing, over clinical data storage is considered a global “blind spot,” requiring a change in management mindset, moving from documentation for “compliance” to documentation for creating evidence of care.

4.2. Factors related to the Quality of Nursing Documentation

The study found statistically significant associations between clinical characteristics and the quality of documentation (Table 6). Patients with high risk factors were inclined to perform more complete documentation, which is possibly attributed to the fact that nurses paid more attention to patients facing the risk of having complications or requiring strict monitoring. However, the difference was not significant (OR = 0.555 in diabetic patients; OR = 0.518 in overweight-obese patients) (Table 6). The study results show that nurses’ educational levels and seniority were linked to the quality of nursing documentation (p<0.05) (Table 7). According to our multivariable logistic regression analysis, nurses who graduated from graduate programs or higher were more likely to provide qualified documentation than those who completed college programs (OR = 2.12; 95% CI: 1.34-3.36; p = 0.028). This finding is consistent with Abebe and Segni (2022) [22], who highlighted that organizational support and training are crucial for improving the quality of nursing records. It underscores that advancing academic qualifications within the Vietnamese nursing workforce is essential for mastering standardized protocols, such as the SWAT tool. This is consistent with previous studies in Vietnam, which also reported significant associations between documentation errors and nurses’ educational level as well as years of experience. In the meantime, age and gender showed no associations of statistical significance with the quality of documentation (p<0.05) (Table 7). This result is similar to that of a study in Jamaica and Ethiopia, where training and instrument standardization were identified as two key factors [3, 5, 17]. Nevertheless, although most nurses completed college (66.8%) and university (30.1%) programs (Table 2), the rate of qualified documentation was low, indicating that educational levels alone (without ongoing training and supervision of clinical practice) were insufficient to ensure documentation quality. Only 25.7% of the nurses were trained in medical record documentation in this study (Table 2); this figure was too low, which may explain the discrepancy in documentation quality across the nine hospitals. Our findings suggest that workload and time constraints were major barriers to high-quality nursing documentation. This suggestion is strongly supported by Abura et al. (2024) [13]. According to 76% of nurses in their study, the lack of time due to heavy patient loads acted as a key barrier to effective documentation. Both studies indicate that hospital administrators should balance the ratios between nurses and patients so that nurses have enough time to write clear records and keep patients safe.

In our study, patient load has a negative association with the quality of documentation (OR = 0.336, p = 0.001) (Table 7). This is consistent with the finding by De Groot et al. (2022) [1], showing a direct positive relation between nursing workload and perceived burden of documentation. This suggests that workload badly affected the quality of clinical documentation, such as that of postoperative wound assessment, due to time pressure. Our study also indicates a significant need for standardized training, as the current quality of documentation remains suboptimal. The lack of structured assessment frameworks is also a factor leading to inadequate documentation practice. According to Moldskred et al. (2021), the use of a plan based on check-up results can greatly improve how nurses record their diagnoses and the interventions they provide [20].

Notably, this current study found substandard documentation, which is an ethical and professional issue. Some medical records lacked information on the status of exudate or odour after surgery, which is not only an administrative shortcoming but also a violation of patients’ right to ongoing monitoring. In the event of a legal dispute, nursing records act as the sole evidence to protect nurses. Our study findings have important implications for nursing practice and hospital management. It is necessary to incorporate standardized wound assessment tools, such as SWAT, into routine nursing documentation. Besides, competency-based training should be held regularly, nurses’ documentation should be routinely examined, and surgical units should have adequate staffing. By carrying out these interventions, the quality of documentation may improve, postoperative wound complications may be detected more easily, thereby enhancing patient safety and continuity of care.

4.3. Limitations of the Study

Limitations that need to be adressed include: (1) The causal association of studied factors with the quality of document were not identified due to the retrospective cross-sectional nature of the study design; (2) The generalization of the study findings to healthcare facilities in Vietnam, especially those whose have different resource allocations or organizational structures, may be compromised, as 1,012 patient records across nine hospitals is modest number; (3) The quality of documentation was our main focus; in other words, we did not pay attention to direct clinical outcomes. We, therefore, cannot say exactly how these documentation gaps caused specific safety incidents. Even after adjusting for key factors, unmeasured confounders, such as hospital safety culture or the type of record system used, may still affect the results.