Bates-Jensen BM, McCreath HE, Harputlu D, Patlan A. Reliability of the Bates-Jensen wound assessment tool for pressure injury assessment: the pressure ulcer detection study. Wound Repair Regen. 2019; 27:(4)386-395

Blackburn J, Ousey K, Stephenson J. Using the new TIME Clinical Decision Support Tool to promote consistent holistic wound management and eliminate variation in practice: Part 5, survey feedback from non-specialists. Wounds International. 2019; 10:(4)40-49

Coleman S, Nelson EA, Vowden P Development of a generic wound care assessment minimum data set. J Tissue Viability. 2017; 26:(4)226-240

Ding S, Lin F, Gillespie BM. Surgical wound assessment and documentation of nurses: an integrative review. J Wound Care. 2016; 25:(5)232-240

Do HTT, Edwards H, Finlayson K. Postoperative wound assessment documentation and acute care nurses' perception of factors impacting wound documentation: A mixed methods study. Int J Clin Pract. 2021; 75:(2)

Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005; 1:(3)58-70

Dowsett C, von Hallern B. The triangle of wound assessment: a holistic framework from wound assessment to management goals and treatments. Wounds International. 2017; 8:(4)34-39

Fletcher J. Development of a new wound assessment form. Wounds UK. 2010; 6:(1)92-99

Gartlan J, Smith A, Clennett S An audit of the adequacy of acute wound care documentation of surgical inpatients. J Clin Nurs. 2010; 2207-2214

Gillespie BM, Chaboyer W, Kang E, Hewitt J, Nieuwenhoven P, Morley N. Postsurgery wound assessment and management practices: a chart audit. J Clin Nurs. 2014; 23:(21-22)3250-3261

Goh HS, Tang ML, Lee CN, Liaw SY. The development of Singapore nursing education system – challenges, opportunities and implications. Int Nurs Rev. 2019; 66:(4)467-473

Gray D, White R, Cooper P, Kingsley A. Applied wound management and using the wound healing continuum in practice. Wound Essentials. 2010; 5:131-139

Greatrex-White S, Moxey H. Wound assessment tools and nurses' needs: an evaluation study. Int Wound J. 2015; 12:(3)293-301

Keast DH, Bowering CK, Evans AW, Mackean GL, Burrows C, D'Souza L. Contents. MEASURE: A proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen. 2004; 12:s1-s17

Little C, McDonald J, Jenkins MG, McCarron P. An overview of techniques used to measure wound area and volume. J Wound Care. 2009; 18:(6)250-253

Low LL. Wound care. The Singapore Family Physician. 2015; 41:(2)27-34

Moore Z, Dowsett C, Smith G TIME CDST: an updated tool to address the current challenges in wound care. J Wound Care. 2019; 28:(3)154-161

Ousey K, Gilchrist B, James H. Understanding clinical practice challenges: a survey performed with wound care clinicians to explore wound assessment frameworks. Wounds International. 2018; 9:(4)58-62

Shepherd J, Nixon M. Standardising wound care documentation in clinical practice: The wound healing assessment and monitoring (WHAM) tool. Wounds UK. 2013; 9:(1)62-66

Qualitative research, 5th edn. In: Silverman D (ed). London: Sage Publications; 2020

Stotts NA, Rodeheaver GT, Thomas DR An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH). J Gerontol A Biol Sci Med Sci. 2001; 56:(12)M795-M799

Welsh L. Wound care evidence, knowledge and education amongst nurses: a semi-systematic literature review. Int Wound J. 2018; 15:(1)53-61

Woodbury MG, Houghton PE, Campbell KE, Keast DH. Development, validity, reliability, and responsiveness of a new leg ulcer measurement tool. Adv Skin Wound Care. 2004; 17:(4)187-196

The state of wound assessment tools in Singapore: an evaluation study

23 June 2022
Volume 31 · Issue 12



Variations in wound assessment and documentation remain an issue for clinicians despite efforts to standardise practices using national guidelines such as the Wound Care Assessment Minimum Data Set (WCA-MDS). As little is known about the quality of the wound assessment tools (WATs) used in Singapore, this study aimed to determine whether the existing WATs used meet the WCA-MDS criteria and clinicians' needs.


The study adopted an action evaluation methodology to evaluate seven well-established WATs, such as the Applied Wound Management (AWM) and National Wound Assessment Form (NWAF), and eight locally-designed WATs against the 34-item WCA-MDS criteria. Two clinicians reviewed the WATs using a self-developed audit form between June and July 2020.


The results show that only five WATs met at least 50% of the 34 criteria indicators, with the MEASURE assessment framework achieving the most at 68%, followed by TIME-CDST at 65%, Hospital C WAT at 56%, NWAF at 53%, and AWM form at 50%. The five most common criteria indicators included wound type/classification, date and time of wound, wound size, wound bed tissue type, and exudate information. Most criteria indicators under the ‘patient information’ and ‘specialist's referral’ subdomains were omitted, reflecting the lack of focus on these areas in the local WATs.


Despite advances in WAT development in the literature, the current state of wound assessment and documentation across healthcare institutions remains inconsistent. There is a need to focus on clinician training and establishing a nationally-validated WAT in Singapore.

Wound assessment remains an integral part of wound care as it provides useful parameters for differentiating wounds that are responding to treatment from those that are not.

However, suboptimal assessment, coupled with inconsistent documentation, can prevent timely treatment and result in delayed wound healing, increased risks for infection, and complications (Gillespie et al, 2014). Therefore, it is important for a clinician to perform wound assessment and documentation in an accurate, consistent, and timely manner (Ding et al, 2016).

Presently, the wound assessment and documentation practices remain inconsistent among different clinicians, institutions, and countries (Coleman et al, 2017). Ding et al (2016) conducted an integrative review of nurses' surgical wound assessment and documentation practices and reported inadequate documentation and inconsistent wound practices despite having national clinical guidelines. They cautioned that this could hamper the quality and monitoring of wound healing progression and treatment.

Register now to continue reading

Thank you for visiting British Journal of Nursing and reading some of our peer-reviewed resources for nurses. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to clinical or professional articles

  • Unlimited access to the latest news, blogs and video content