Admission Proforma Significantly Improves the Medical Record

Diver, Andrew J.; Craig, B

doi:10.1177/003693300505000304

Cited by 16 publications

(9 citation statements)

References 2 publications

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“…We also assessed whether the implementation of a proforma makes it easier for healthcare professional to take coherent notes. This study illustrates that a surgical clerking proforma improves the quality of patient documentation, which is consistent with previous studies [2], [7], [8], [9].…”

Section: Discussionsupporting

confidence: 92%

Completeness in clerking: The surgical admissions proforma

Bhanot

Abdi

Bamania

et al. 2017

Annals of Medicine &Amp; Surgery

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BackgroundThe accessibility of surgical patient data is a key safety concern, and relies on efficient clerking and handovers. This project assessed whether the introduction of a surgical clerking proforma improved the recording of patient information in the surgical admissions unit (SAU) at Northwick Park Hospital.Materials and methodsExisting patient notes were assessed on content and ease of access, using two independent surveys conducted over a 5-day period. The first survey audited patient notes before (n = 28) and after (n = 23) the introduction of the proforma. It assessed whether key patient details were documented, in line with the 17 criteria set out in the Guidelines for Clinicians on Medical Records and Notes by The Royal College of Surgeons in England. The second survey questioned healthcare professionals before (n = 25) and after (n = 17) proforma implementation on the accessibility of patient data and coherency of patient notes.Results5 of the 17 criteria showed significant differences post proforma implementation. Of these differences, the recording of height and occupation was most notable (p < 0.01). Medication history, weight and investigations also showed significant increases in documentation (p < 0.05). In all 3 questions asked to healthcare professionals, fewer healthcare professionals were required to revisit archived notes following proforma implementation (p < 0.05).ConclusionOur study illustrates that a comprehensive surgical clerking proforma improves patient data documentation and saves healthcare professionals' time compared to the freehand clerking method. The implications of such work are far reaching, and if well implemented could allow a new reliable platform for further clinical audits.

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Section: Discussionsupporting

confidence: 92%

Completeness in clerking: The surgical admissions proforma

Bhanot

Abdi

Bamania

et al. 2017

Annals of Medicine &Amp; Surgery

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“…While no study, to our knowledge, has previously looked at the use of customised diagrams, this result is consistent with previous findings, which have shown that the use of preprinted proformas improves the quality of documentation during admission 3 4. There is also evidence that structured documentation improves legibility and thus enhances the interpretation of clinical records 5 6.…”

Section: Discussionsupporting

confidence: 90%

A customised ENT admissions proforma and novel online ‘clerking collaborative’

et al. 2016

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Objectives Admissions clerking proformas are commonly used in hospitals to aid complete patient assessment. Much variation remains in the format of these forms and they frequently fail to account for local-specific and specialtyspecific factors. We developed and piloted the use of a novel ear, nose and throat (ENT) clinic admissions clerking proforma and created a national online 'clerking collaborative'. Methods Doctors completed 'mock clerkings' for 6 common acute ENT presentations by both traditional methods (freehand) and using our customised ENT diagrams. Participants were timed throughout the process and asked to complete a feedback survey. A senior ENT clinician provided structured feedback comparing the quality of each type of clerking. Results 9 junior doctors participated in the exercise. 5 participants started with freehand drawings while the remainder used our clerking proforma first. Our customised diagrams provided accurate representations of the clinical scenarios, and were easier and faster to complete than free drawings. They were also easier to interpret and best represented the clinical findings compared with freehand clerkings. A website (MyClerking.co.uk) was created to disseminate the clerking proforma and to allow other clinicians to contribute improvements. Conclusions Accurate and legible clerkings are essential to allow for continuity of care and management. This is particularly important in ENT, where drawings are frequently used to describe clinical findings. Our predrawn diagrams speed up the clerking process and allow for more accurate depiction of findings. We have designed an online 'clerking collaborative' where doctors can download our proforma, contribute improvements and upload their own ideas for other specialties.

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“…Contributing factors include limited time available for clerking new patients, and numerous demands placed on junior doctors responsible for ensuring that wards run smoothly. [12] One way to address these issues is to produce standardised preprinted medical admission sheets for junior doctors to use as prompting tools. Many studies have provided Table 2 evidence that preprinted pro formas for patient admission are effective in overcoming problems with incomplete medical records.…”

Section: Discussionmentioning

confidence: 99%

“…Many studies have provided Table 2 evidence that preprinted pro formas for patient admission are effective in overcoming problems with incomplete medical records. Not only do these forms increase data capture, [12][13][14] but they also make the process of gathering clinical information at the point of admission more efficient and less time-consuming. These findings have been replicated in hospitals across the world, including in Africa.…”

Section: Discussionmentioning

confidence: 99%

Acute kidney injury risk factor recognition in three teaching hospitals in Ethiopia

et al. 2013

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Background.A key objective of the Nephrology Sister Centre Programme between the renal units in Cardiff and Addis Ababa, sponsored by the International Society of Nephrology, is to facilitate development of the local clinical service in Ethiopia specifically focused on the management of acute kidney injury (AKI). Objectives. To examine the relationship between AKI risk factor recognition and monitoring of renal function in three hospitals in Ethiopia. Methods. Cross-sectional data were gathered regarding renal function monitoring, recording the presence of AKI risk-associated comorbidities and prescription of nephrotoxic medications across the disciplines of medicine, surgery, obstetrics and gynaecology. Results. Patients were more likely to have their renal function checked at the hospital with specialist services. Across all centres, the highest proportion of patients who had renal function measurements were those admitted to a medical ward. There was a positive relationship between documented comorbidities and the measurement of renal function but not between the prescription of nephrotoxic drugs and measurement of renal function. Conclusion. There was great variability in the extent to which doctors recognised the presence of risk factors for the development of AKI. Failure to identify these risk factors represents a lost opportunity to identify patients at high risk of developing renal injury who would benefit from renal function monitoring.

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Admission Proforma Significantly Improves the Medical Record

Cited by 16 publications

References 2 publications

Completeness in clerking: The surgical admissions proforma

Completeness in clerking: The surgical admissions proforma

A customised ENT admissions proforma and novel online ‘clerking collaborative’

Acute kidney injury risk factor recognition in three teaching hospitals in Ethiopia

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