285 ‘Smart Phrase’ Ward Rounds: Do They Improve Documentation and Efficiency?

Abstract

Abstract Aim Accurate ward round documentation plays a crucial role in patient management. In the last two years, UCLH has introduced EPIC software. This gives opportunity to create templates for repetitive processes (‘smart phrases’). The aim of this project was to assess if the introduction of ‘smart phrase’ templates can improve the quality of ward round documentation. Method Following consultation, 5 fundamental domains were agreed to be included in the template, namely: Procedure and postoperative day, current clinical issues, physical examination, objective assessment (including vital signs, fluid balance/drains, blood tests, DVT prophylaxis, antibiotic status), and 24h treatment plan. A baseline audit was performed, then the new template was introduced. Two PDSA cycles were performed, for 3 weeks after introduction, and repeated two months later. Chi-square tests was used to assess statistical significance of change (p<0.05). Results A statistically significant improvement in documentation for all domains - apart from ‘current clinical issues’ and ‘24h planning', which were well documented to start - was observed after the introduction of smart phrases; with an average improvement of 34.8% (range 0–65.6%). The improvement was maintained at 2 months (improvement from baseline 35.1%, range 0–59%). A small decrement in documentation occurred between introduction and the 2-month PDSA assessments in some domains (mean change 0.7%, range -12.3 to 23%), although this was not statistically significant. Conclusions The introduction of smart phrases significantly improved ward round documentation of important parameters. Evolution of additional smart phrase is expected to further improve the accuracy leading to more efficient decisions and safer clinical practice.