Using a proforma to improve standards of documentation of an orthopaedic post-take ward round

Abstract

In Trauma and Orthopaedics, a daily Trauma Meeting (TM) occurs, where the previous 24-hour take is discussed and a management plan is decided by the consultant on-take. The post-take ward-round (PTWR) usually follows. In the district general hospital (DGH) where this audit was conducted, clinical incidents and root-cause analysis revealed that the TM/PTWR documentation were suboptimal.We identified gold standards. Variables included clear documentation of PTWR, date/time, consultant on-take, clinician leading the wardround, and management plan. 50 cases were reviewed retrospectively. 72% were seen on PTWR. 47% of these were clearly labeled PTWR. 64% of the cases not seen on PTWR were weekend admissions. Documentation of the previously mentioned fields were also poor.Audit results were presented at the department meeting and a Trauma Meeting/Post-Take Ward Round Proforma was implemented. A prospective re-audit of 50 cases revealed that patients not seen on a PTWR decreased to 18%; 4% of these were weekend admissions. 88% of patients seen had a proforma completed. 18% of all cases did not have a proforma.

A quality improvement project using a problem based post take ward round proforma based on the SOAP acronym to improve documentation in acute surgical receiving

“…Due to the fact that the study had approximately 50 patients in each arm in both study periods, involving multiple different surgical teams, we believe this study reasonably reflects the normal practice for documentation of surgical patients in our hospital and Greater Glasgow and Clyde. The effectiveness of ward round proformas has been reported in the past but and has been shown to improve patient care by increasing the accuracy and completeness of written communication between healthcare professionals [5] . The importance of full and contemporaneous documentation is particularly apt in general surgical receiving due to the fast pace and the pressures of time of surgical ward rounds [1] .…”

“…In the busy highly charged atmosphere of surgical ward rounds proformas can be invaluable. They can act as an aide-mémoire for the member of staff carrying out the documentation thus reducing the potential for important information to be missed [5] .…”

“…The improvement cycle was not repeated a third time due to the hospital closing its doors and being absorbed into a larger institution. But there is evidence of maintained standards from a recent study carried out in an orthopaedic setting where average compliance with proforma headings remained at 96% after the last audit cycle [5] . This was a very similar study to this one and as such it would suggest that the gains achieved with this study could be maintained [5] .…”

“…There has been a significant amount of strong research assessing the effectiveness of using post take proformas to ensure the accuracy and completeness of documentation in the setting of acute medical receiving, orthopaedics and most recently surgical receiving in New Zealand and London [1] , [4] , [5] , [6] . However to our knowledge nothing has been conducted in the literature to ascertain the effectiveness of using a problem based proforma in an acute general surgical receiving setting.…”

“…It has generally been accepted that certain aspects of ward round documentation are essential including the name of the person conducting the ward round, the time and date of the round and finally the impression/diagnosis and plan. These are universally accepted requirements but they can sometimes be missed out due to time constraints and inexperience on the part of the people making the notes [5] . The SOAP acronym has long been used to help ensure contemporaneous notes in an unofficial way but this study combines this with the known effectiveness of proformas to ensure adequate documentation.…”