The surgical admission proforma: the impact on quality and completeness of surgical admission documentation

Hannan, Enda; Ahmad, Abrar; O’Brien, Aoife; Ramjit, Sinead; Mansoor, Shahbaz; Toomey, Deirdre

doi:10.1007/s11845-020-02475-1

Cited by 3 publications

(2 citation statements)

References 14 publications

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Section: Introductionmentioning

confidence: 99%

“…The admission note serves as a reference point throughout a patient's care journey for caregivers seeking patient information [9]. Standardised admission proforma has been demonstrated to be an effective tool to maintain high-quality documentation [9][10][11]. Proponents reason that they act both as an aide memoire for junior clinicians clerking patients' admissions while also improving legibility and aiding time efficiency [11].…”

Section: Introductionmentioning

confidence: 99%

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Improving Acute Orthopaedic Admission Note Documentation Standards at a Tertiary Centre Through Proforma Introduction: A Quality Improvement Initiative

O’Driscoll¹,

Condell²,

O’Sullivan³

et al. 2022

Cureus

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BackgroundClear, accurate written documentation plays an important role in the handover of medical information, helping to improve care efficiency and avoid medical errors. Both HSE and the Irish National Orthopaedic Models of Care guidelines include key documentation standards for admission notes. Standardised medical admission proforma can help improve documentation standards, but their usage across Irish orthopaedic units is limited to three centres. We evaluated whether an admission proforma improved the documentation standards of acute orthopaedic trauma admission notes within our regional trauma unit. MethodsCycle 1 consisted of a retrospective review of 50 consecutive acute orthopaedic trauma admissions. Exclusion criteria included planned admissions, age <16 years, spinal or pelvic trauma, and 'hip' fractures for whom an existing proforma was in use. Cycle 2 consisted of a prospective review of 50 consecutive acute trauma admissions using the new proforma. Each cycle was scored against a pre-determined checklist incorporating Irish Health Service Executive and Orthopaedic Models of Care documentation standards, with results collated and statistical analysis then performed using Fisher's exact test. FindingsSignificant improvements in admission note compliance with national documentation were observed. This encompassed multiple domains including clinical identification, e.g., consultant identification (78% to 100% p=0.0005), clinical history, time of injury (72% to 100% p=0.0001), medical history, smoking status (86% to 100% p=0.0001), and patient assessment, vital signs (28% to 70% p=0.0001). ConclusionImprovements in admission note compliance with national documentation standards followed the introduction of a standardised proforma. These findings may encourage the introduction of similar proforma in other units, with potential benefits in patient care.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Improving Acute Orthopaedic Admission Note Documentation Standards at a Tertiary Centre Through Proforma Introduction: A Quality Improvement Initiative

O’Driscoll¹,

Condell²,

O’Sullivan³

et al. 2022

Cureus

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Value of an orthopaedic admission proforma

Akasha,

Boughton,

Cleary

2024

BMJ Open Qual

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BackgroundAdmission notes are an important aspect of clinical practice and a vital means of communication among healthcare professionals. Incomplete or poor clinical documentation on admission can lead to delayed surgery.Patients and methodsA retrospective analysis of 20 consecutive admission notes to our department was compared against the Royal College of Surgeons standards (GSP 2014). A new admission proforma was designed, and after the introductory period, two further retrospective cycles were performed.ResultsIn total, 60 admission notes were analysed. Following the introduction of the proforma, there was an overall improvement in the documentation of the quality and quantity of notes studied.ConclusionOur study demonstrated that a well-structured admission protocol can improve the overall quality of admission notes.

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Effectiveness of a Structured Trauma Template in Improving Clinical Examination Accuracy in Maxillofacial Trauma: A Prospective Study

Pandey,

PG,

Rajanna

et al. 2024

Craniomaxillofacial Trauma & Reconstruction

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Study Design Prospective pre-post study. Objective Maxillofacial trauma presenting to the emergency department (ED) are often accompanied with complex concomitant injuries, thereby making thorough diagnosis and treatment plan quite an exacting task owing to the demanding conditions of the ED. The use of a structured maxillofacial trauma template helps in documenting the injuries comprehensively, aids in treatment planning, avoids medical negligence thereby improving the quality of care given to the patient. The study introduced a structured maxillofacial trauma template to improve the quality of the ED documentation. Methods A total of 220 patients were evaluated for the quality of their ED documentation from September 2023 till February 2024. The group A included 110 patients where complete medical documentation was done routinely on a blank A4 sized paper, group B included 110 patients where the documentation was done using the structured oral and maxillofacial trauma template. The ED notes were thoroughly evaluated by the 2 independent authors for record completeness and documentation rate of history and examination findings. Results The introduction of trauma template demonstrated a significant improvement of 18.95 % in record completeness. Significant improvement was seen in documentation rate among the covariates like place of injury, time of evaluation, primary care given, wound classification, dento-alveolar injury, ophthalmic evaluation, nerve injury evaluation, comorbidities with P = .001, and referral with P = .03. The ophthalmic evaluation showed significant improvement among covariates (loss of visual acuity, reflexes, diplopia, enophthalmos, subconjunctival haemorrhage, chemosis, periorbital oedema, periorbital ecchymosis, ocular dystopia) with P = .001, and extraocular muscle restriction with P = .004. Conclusions The study demonstrated that the use of a structured oral and maxillofacial trauma template can significantly improve the quality of the ED documentation and contributes to better patient care in the ED.

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The surgical admission proforma: the impact on quality and completeness of surgical admission documentation

Cited by 3 publications

References 14 publications

Improving Acute Orthopaedic Admission Note Documentation Standards at a Tertiary Centre Through Proforma Introduction: A Quality Improvement Initiative

Improving Acute Orthopaedic Admission Note Documentation Standards at a Tertiary Centre Through Proforma Introduction: A Quality Improvement Initiative

Value of an orthopaedic admission proforma

Effectiveness of a Structured Trauma Template in Improving Clinical Examination Accuracy in Maxillofacial Trauma: A Prospective Study

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