Kalsoom Altaf
Introduction: Good Surgical Practice Guidelines 2014 (Royal College of Surgeons) state that 'surgeons must ensure that accurate, comprehensive legible and contemporaneous records are maintained of all their interactions with patients'. In June 2019, a retrospective study was performed at Broomfield Hospital (United Kingdom), assessing the quality of Post-Take Ward Round documentation in Trauma and Orthopaedic patients in a two week period. We aimed to evaluate the impact of a new Post-Take Ward Round (PTWR) proforma on Trauma and Orthopaedic documentation and the opinions of Allied Health Professionals (AHPs).
Methods: By assessing notes of emergency patients and their adherence to the national Good Surgical Practice Guidelines 2014 (Royal College of Surgeons), areas for improvement were identified and a proforma created and implemented. Audit variables included documentation of the following: patient identifiers, date and time, consultant on-take, presenting complaint, discussion with patient/relatives, management plan and documenting clinician. After three months, this was re-audited with data collected from all admissions within a two week period alongside spot questionnaires completed by AHPs.
Results: There was an improvement in recording the responsible clinician (48% to 100%) and documenting clinician (49% to 63%), history and examination (58% to 73%), initial diagnosis (68% to 92%) and management plan (35% to 98%). However, documentation of patient identifiers dropped (60% to 30%) alongside date and time (73% to 30%). 42% of AHPs agreed that documentation had improved since introduction of the proforma, whilst none of the respondents said that documentation had worsened.
Conclusion: The proforma has led to improvements in both adherence to national guidelines and satisfaction amongst the AHPs thereby providing swift communication between the multidisciplinary team.
