531 An Admission Proforma to Improve Clerking Documentation in the ENT Department During the Covid-19 Pandemic: A Full Cycle Audit

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Abstract Aim Good Surgical Practice states that surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained for all their interactions with patients. It is therefore critical that the clerking document, as the initial record of an admission, meets this standard. During the Covid-19 pandemic, an emergency rota meant that cross-covering of ENT at junior level was increasingly required in our hospital. Understandably, these trainees were less familiar with admitting ENT patients and of departmental standards. Our aim was to evaluate the quality of clerking documentation in our department during this period and investigate whether a standardised admission proforma could improve this. Method Clerking documents for all patients admitted in April 2020 were checked for completion of venous thromboembolism (VTE) risk assessment and inclusion of ten key pieces of information as outlined by the Surgical Tool for Auditing Records score. As was standard at this time, all clerking documentation had been completed on blank hospital continuation paper. A departmental admission proforma was introduced before admissions in June 2020 were then assessed identically. Results Improvement was noted in all measured parameters with no adverse effects. There was particular improvement in documentation of referral source (28% to 97%), consultant in charge (35% to 90%), name/grade/bleep (25% to 94%) and VTE risk assessment (14% to 78%). Trainee response was positive. Conclusions A simple admission proforma can markedly improve the standard of clerking documentation and therefore increase patient safety during a turbulent time. We would encourage other departments to consider developing their own.