Abstracts of free papers presented at the annual meeting of the Obstetric Anaesthetists’ Association, Edinburgh, 26 - 27 May 2011

Abstract

Introduction: Inconsistent and poorly structured content in admission and discharge notes can lead to adverse clinical incidents. Structured medical records improve health care professional performance, patient outcome and quality of information available for audit and research. A structured obstetric specific admission and discharge proforma was introduced to our obstetric high dependency unit (HDU) with the aim of improving patient safety. The admission sheet documents basic demographics, diagnosis, mode of delivery and specific monitoring requirements. The discharge section includes a tick-box systems review, investigation summary and ongoing treatment plan. We audited the impact of the proforma on the adequacy of information documented in HDU notes. Methods: Case notes of mothers admitted to HDU prior to proforma introduction were retrospectively reviewed for recording of information requested on the new standardised medical record. A program of education emphasising practical use and importance of completion accompanied the introduction of the proforma. A prospective case note review of mothers was then completed using solely the admission and discharge proforma for information collection. Results: 20 case notes were reviewed prior to introduction and 10 case notes after.