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Post-acute surgical ward round proforma improves documentation.

ABSTRACT: In health care, record keeping of doctor-patient encounters is vital for quality patient care and medico-legal reasons. We audited the documentation of post-acute consultant ward round (PACWR) in our department before and six months after an introduction of a proforma (standard form). The clinical notes of all patients admitted acutely under General Surgery over a period of one week before and one week after the introduction of a proforma were reviewed to note whether time and date, signature, impression and dietary plan were documented after PACWR. The nurses were also surveyed on the day of the PACWR for their certainty regarding the dietary plan of their patients and whether they had to contact the surgical team for clarification. There were 108 and 103 patients eligible for the first and second study periods respectively. After the introduction of the proforma, there was a statistically significant improvement in the documentation of time and date (37% vs. 72%, p-value < 0.01) and impression (40% vs. 61%, p-value < 0.01). Improvement in the documentation of the dietary plan reached statistical significant only when the analysis was restricted to the cases where a proforma was filled out (78 out of 103 patients). Introduction of the proforma had no statistically significant impact on the nurses' certainty regarding their patients' dietary plan and the number of times they had to contact the surgical teams. In conclusion, PACWR proforma improves overall documentation. This will help in avoiding adverse effects on patient care and medico-legal ramifications.

SUBMITTER: Al-Mahrouqi H

PROVIDER: S-EPMC4652723 | biostudies-literature | 2013

REPOSITORIES: biostudies-literature

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Post-acute surgical ward round proforma improves documentation.

Al-Mahrouqi Haitham H Oumer Ramadan R Tapper Richard R Roberts Ross R

BMJ quality improvement reports 20130517 1

In health care, record keeping of doctor-patient encounters is vital for quality patient care and medico-legal reasons. We audited the documentation of post-acute consultant ward round (PACWR) in our department before and six months after an introduction of a proforma (standard form). The clinical notes of all patients admitted acutely under General Surgery over a period of one week before and one week after the introduction of a proforma were reviewed to note whether time and date, signature, i ...[more]

PMID: 26734192

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Project description:Regular consultant ward rounds have been shown to reduce the length of stay and improve the discharge planning for patients (1). To balance the competing demands of outpatient activity and inpatient oncology, it has been difficult to provide specialist care in our hospital. Previously, inpatients were managed primarily by the oncology specialist trainees, who are qualified in internal medicine, with an ad-hoc review by their named consultant. A regular consultant ward round was introduced for the first time on the 7/1/13. Each consultant was timetabled to give a twice weekly morning ward round on a rolling rota. To evaluate this intervention, a retrospective case note analysis was undertaken. This included all patients admitted under oncology for the two months preceding and succeeding the new ward round. For each patient the admission date, time to first consultant review, number of consultant reviews, time to discharge after consultant review, and discharge date was identified. A staff survey also took place. Statistical analysis was performed using Mann-Whitney U or Chi-Squared tests. 85 patient episodes met the inclusion criteria. Case notes were available for 63 episodes (74%). The average length of stay significantly decreased from 11 days to three and half days (p<0.05). The time to discharge after first consultant review also significantly decreased from six days to two days (p<0.05). The number of consultant reviews and time to first consultant review remained unchanged (p>0.05). The percentage of patients receiving a consultant review increased, from 54.3% to 71.4%, though this was not statistically significant. However it is likely such a large increase is clinically significant. Medical and nursing staff satisfaction also improved. This study suggests that a regular consultant ward round improves length of stay for patients. This is possibly because an increase in patients received a consultant review and that the treatment and discharge decisions were expedited after such a review.

Dataset Information

Post-acute surgical ward round proforma improves documentation.

Publications

Post-acute surgical ward round proforma improves documentation.

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