1396 Improving Documentation During A General Surgical Ward Round

Abstract

Abstract Introduction Clear documentation at ward rounds is essential to patient safety. The purpose of this audit was to identify areas that could be improved in the documentation at surgical ward round. Method A retrospective audit of the most recent ward round entry, in two surgical wards, was carried out against the Royal College of Physicians ‘Generic Medical Record Keeping Standards’. Patient name, Health & Care number (HCN), date, time(24hr), senior doctor present, signature, printed name, GMC/contact details of the scribe were analysed. After data collection, the standards were circulated to all doctors during departmental teaching and displayed on note trollies. A re-audit was then undertaken. Chi-square test was used to compare the two audit cycles and p value of < 0.05 was considered significant. Results 21 patient notes were analysed in the initial audit. Patient name and HCN was noted in 86%(18/21) and 67%(14/21) respectively. 100% of notes included date and senior doctor. Time of entry, signature and printed name/Bleep/GMC number were noted in 81%(17/21), 90.5%(19/21) and 57%(12/21) respectively. 24 patients were included in the re-audit. Results revealed improvement in all parameters as follows: patient name (95.8% 21/24;p=0.23); HCN (91.6%; 22/24;p=0.036),; date and senior doctor (100% as before); time (87.5%; 21/24;p=0.55); signature (100%; 24/24), and printed name/GMC/bleep (87.5%; 21/24;p=0.022). Conclusions This closed loop audit demonstrates an overall improvement in the quality of surgical documentation at ward rounds with a very simple intervention. Additionally, a statistically significant improvement was noted in recording HCN and printed name/GMC/bleep.