1651 Improving Surgical Admission Clerking in A Major Trauma Centre – The Role of a Standardised Clerking Proforma

Abstract

Abstract Introduction High quality medical records are integral to Good Medical Practice in the UK, for provision of good patient care. This study assesses the effectiveness of a structured Surgical Assessment Proforma in improving documentation, within the Surgical Assessment Unit (SAU) of a major trauma centre. Method A four-phase prospective study was undertaken – using PDSA methodology. This included: initial clinician survey and proforma development, audit, re-audit post-implementation, and final user survey. Evaluation and proforma design utilised standards from the RCS(Eng) and the PRSB. Notes of all patients admitted to the SAU, over two separate one-week periods, were assessed for completeness of documentation. Statistical analysis employed T-Test, with a P value of < 0.05 considered significant. The study was considered service evaluation, and therefore exempt from ethical approval. Results Pre-Proforma Survey 100% of respondents felt a proforma would be beneficial. 77% believed key elements of clerking were missed within the previous system. Cycle 1 (n = 62) Of note, assessment categories lacking information were: Responsible Consultant, Medication History, Allergy Status and Differential Diagnosis. Cycle 2 (n = 119) Of 45 assessment criteria: 38 improved (23 significantly (P < 0.05)), 2 showed no change, 5 were reduced (2 significantly (P < 0.05)). Documentation rates in nine categories improved by over 50%. Post-Proforma Survey 73% of doctors and 86% of allied health professionals (AHPs) agreed documentation improved with proforma use. 66% of clinicians agreed proformas reduced omission of essential information and provided safe clerking guidance for doctors. 100% of AHPs agreed the proforma improved handover. Conclusions In a major trauma centre SAU, standardised proforma use improves completeness of clerking.