1251 A Project Aimed at Improving the Completeness and Quality of Admission Clerking in the ENT Department

Abstract

Abstract Aim Admissions notes are essential in communicating information regarding patients. The project aimed to improve the proportion of completed admission clerking and the quality of the recorded data for the ENT patients admitted to the ward. Method We have included emergency presentations and elective admissions for moderate and major head and neck surgery. Patients were identified from handover lists. Baseline data were collected across a period of six weeks, and 103 admission notes were included. Following the intervention, the data collection lasted another six weeks, and 93 documents were identified. Documents were compared against The Royal College of Surgeons of England Guidelines for Clinicians on Medical Records and Notes. Interventions to improve the standard of admission clerking included: a short departmental presentation, educational posters, and an introduction of the electronic clerking proforma. Results Following the intervention, the proportion of completed admission clerking has increased and the quality of recorded data has improved.The proportion of completed admission clerking increased from 95.4% to 100% for emergency presentations, and from 2.6% to 68.2%for elective admissions. Data completeness has improved across all documentation domains. For emergency presentations, the most notable improvement was recorded for the medication history (76.9% vs 93.0%) and allergy status (73.9% vs 87.3%). For elective admissions, the greatest improvement was noted for past medical history (2.6% vs 65.6%) and social history (0% vs. 56.5%). Conclusions In conclusion, the use of clerking proforma alongside educational presentation and posters increased the completeness and quality of admission clerking, for both emergency and elective presentations in the ENT department.