Authors: (including presenting author): :
Wu WSF (1), Ho CH (2), Lai FSP (1), Leung SH (1), Ko SH (1)
Affiliation: :
(1) Department of Family Medicine and Primary Healthcare, Kowloon Central Cluster ; (2) Buddhist Hospital, Kowloon Central Cluster
Keyword 1: :
Stitches/Staples Removal
Keyword 2: :
Clinical Photo Recording
Keyword 3: :
Nursing Audit on Documentation
Introduction: :
Accurate nursing documentation and strict adherence to aseptic techniques are essential for safe and effective wound management. In primary healthcare settings, the removal of stitches and staples, along with clinical photo recording, requires meticulous compliance with established standards to ensure patient safety and continuity of care. Inadequate documentation or procedural lapses may result in adverse incidents such as retained or missing stitches, infection, or delayed wound healing. To strengthen clinical governance and enhance quality assurance, the Kowloon Central Cluster (KCC) Family Medicine and Primary Healthcare (FM&PHC) initiated a structured nursing audit to evaluate compliance with documentation and procedural standards related to wound care.
Objectives: :
The primary objective of this audit was to assess nursing staff compliance with established standards for documentation, stitches/staples removal, and clinical photo recording. The audit aimed to identify areas for improvement, enhance patient safety, and minimize risks associated with incomplete wound care practices.
Methodology: :
A cross-sectional audit was conducted across Family Medicine Centres (FMCs) within KCC. All nursing staff involved in wound care were included as auditees. Data were collected using a standardized audit form assessing compliance through direct observation, auditee interviews, and documentation review. Advanced Practice Nurses (APNs) served as auditors. The audit process included staff briefing, training, and coaching from 13 to 19 October 2025, followed by the auditing period from 20 October to 9 November 2025. Audit results were analyzed by 14 December 2025. Critical criteria included verification of valid prescriptions, double-checking stitch/staple counts before and after removal, adherence to aseptic techniques, and obtaining verbal consent for clinical photo recording
Result & Outcome: :
A total of 101 nurses were assessed, including 86 community-based and 15 hospital-based staff. The audit demonstrated 100% compliance across all 26 standard criteria, reflecting consistent excellence in documentation and procedural practice. Full compliance was achieved in all critical areas, including prescription verification, aseptic technique adherence, accurate stitch/staple count checks, and patient consent for photography. Nurses also maintained strict confidentiality and accurate labeling in clinical photo documentation. The audit effectively reinforced the importance of standardized wound care practices and comprehensive documentation in minimizing clinical risks. Continuous education, standardized audit tools, and regular performance reviews are recommended to sustain quality improvement and prevent incidents related to retained or missing stitches or clips.
