German national consensus on wound documentation of leg ulcer. Part 1: Routine care - standard dataset and minimum dataset

Background. Standards for basic documentation and the course of treatment increase quality assurance and efficiency in health care. To date, no standards for the treatment of patients with leg ulcers are available in Germany. Objectives. The aim of the study was to develop standards under routine conditions in the documentation of patients with leg ulcers. This article shows the recommended variables of a "standard dataset" and a "minimum dataset". Materials and methods. Consensus building among experts from 38 scientific societies, professional associations, insurance and supply networks (n = 68 experts) took place. After conducting a systematic international literature research, available standards were reviewed and supplemented with our own considerations of the expert group. From 2012-2015 standards for documentation were defined in multistage online visits and personal meetings. Results. A consensus was achieved for 18 variables for the minimum dataset and 48 variables for the standard dataset in a total of seven meetings and nine online Delphi visits. The datasets involve patient baseline data, data on the general health status, wound characteristics, diagnostic and therapeutic interventions, patient reported outcomes, nutrition, and education status. Discussion. Based on a multistage continuous decision-making process, a standard in the measurement of events in routine care in patients with a leg ulcer was developed.