Improving the weekend spinal ward round at a major trauma centre.

Abstract

Documentation is key for communicating between members of the multidisciplinary team, allowing for better care, but documentation for spinal patients in the authors' centre was poor. Every ward round encounter was analysed for six weekends. Data were analysed and presented to the department. A weekend ward round proforma was designed to help improve ward-round documentation. Ward round entries were then re-audited over four weekends to assess the usefulness of the new proforma. A total of 69 patient encounters were analysed in cycle 1, 58 in cycle 2 and 92 in cycle 3. In cycle 1, 80% of encounters had inadequate documentation. Following introduction of the ward round proforma there was a significant improvement in documentation in six out of fields, which was maintained in four out of seven fields 2 years later. The authors believe that this improvement may avoid adverse effects on patient care, streamline doctors' time and reduce medicolegal consequences.