Ward Round Proforma Research Articles

HPB SO63 - A Closed-Loop Audit on Surgical Ward Round Documentation in a Tertiary Hospital

Abstract Background Surgical ward rounds play a pivotal role in overall patient outcome during surgical and perioperative care. Clear and comprehensive documentations are crucial in providing an accurate account of ward round activities. We aimed to assess the quality of hepatopancreatobiliary (HPB) ward round documentation and the impact of a HPB surgical ward round proforma on the quality of documentation. Method 50 medical notes were reviewed in a tertiary centre to determine if key components of ward round documentation such as the date, time, diagnosis, procedure, consultant, person documenting, information communicated to patient, observations, investigations and management plan were documented. A proforma for ward round documentation was introduced. A re-audit was performed to review the impact of a proforma on ward-round documentation. Results The time of ward round, relevant history, NEWS and management plan were recorded in more than 50% of medical notes. However, the diagnosis, consultant, person documenting, information communicated to patient, wound review, medication review, fluid balance, investigations, follow up and discharge plans were documented in less than 50% of medical notes. After the introduction of a proforma, the date and time of the surgical ward round were documented in 94% of medical notes. 84% had initials of the consultants leading ward-rounds and the person documenting. More than 80% notes included relevant examination, information communicated to patient, wound and medications review. Conclusion Surgical ward round proformas have a role in improving ward round documentation. Good record keeping is essential for continuity of care, optimising quality of care and ensuring patient safety.

WP1.18 - A Surgical Post-Take Ward Round Checklist Proforma: A Prompt for Improved Documentation

Abstract Aims Surgical ward rounds are often swift, therefore documentation of diagnostic and management decisions is frequently incomplete. The Royal College of Surgeons of Edinburgh (RCSEd) devised a ward round checklist toolkit to improve documentation of surgical post-take ward rounds. Methods We conducted a baseline audit of our district general hospital general surgery post-take ward round documentation, based on the RCSEd checklist. Documentation in each domain was recorded for each ward round entry for both pre and post intervention groups. Control patients were identified from the surgical take list across 7 different days in a month. The checklist toolkit was then adapted into a proforma for our institution and used on post-take ward rounds for a trial period of 7 days. Results 40 patients were included in the pre-intervention group, 17 in the post intervention group. Following the introduction of the post take ward round proforma, documentation of most recent observations improved from 40% to 82%, admission blood results from 27.5% to 94%, and imaging results from 42% to 90%. Areas of existing good practice improved; history and examination findings were documented in 100% of patients, an improvement from 80% pre-intervention. Nil by mouth status was documented in 80% of cases, up from 50%, and IV fluid requirement in 58%, up from 10%. Conclusions A proforma for post take ward rounds improved documentation of key diagnostic and management information. As a result, we recommend a standardised approach to documentation to encourage consistency of recording key information in the patient record.

269 Quality Improvement: Implementing a General Surgery Ward Round Proforma at Stoke Mandeville Hospital

269 Quality Improvement: Implementing a General Surgery Ward Round Proforma at Stoke Mandeville Hospital

741 Introducing a Ward Round Proforma to Improve Surgical Ward Documentation

741 Introducing a Ward Round Proforma to Improve Surgical Ward Documentation

347 General Surgery Ward Round Documentation: A Quality Improvement Project

Abstract Aim To improve the rate of inclusion, and quality, of important clinical details in the ward round documentation of General Surgery inpatients at a district general hospital. Method A 15-point ward round checklist was created, containing clinical details which were considered appropriate to be included in all wards round entries. An initial audit of 71 ward round entries was performed, assessing their compliance to this checklist. Following this, a ward round proforma was created and put into use. One month later, 106 wards round entries were sampled for a repeat audit, 85 of them having used the ward round proforma (80.2% compliance). These 85 entries were then analysed for compliance against the checklist, and results compared to the first cycle. Results Use of the proforma demonstrated improvement in 11 out of 15 checklist components, with one component (a documented management plan) remaining at 100% compliance. The proforma achieved an 100% compliance of 3-point patient identification (+43.7%), with dramatic improvements in the documentation of NEWS score/observations (+22.5%), medication review (+26.7%), thromboprophylaxis review (+53.4%), examination findings (+45.3%) and escalation/DNACPR status (+37.7%). The 3 components where performance declined were the name of the ward round lead (-8.5%), date (-2.4%) and time (-10.6%), most likely due to design of the proforma which has been rectified and will be reaudited to ensure improvement. Conclusions Using a ward round proforma greatly improves consideration and documentation of important clinical details on ward rounds. This has positive implications for patient safety and facilitates the subsequent ongoing care of the patient.

IMPROVING ONGOING PATIENT CARE THROUGH GUIDING DOCUMENTATION OF WARD ROUNDS: A QUALITY IMPROVEMENT PROJECT IN A GENERAL SURGICAL UNIT WITHIN THE NATIONAL HEALTH SERVICE

Aim: Increasing pressures within the National Health Service has led to busier ward rounds. Documentation of information can be sacrificed to accommodate the pace of (ward) rounds. This quality improvement project aims to implement a user-friendly proforma for surgical ward rounds, with the view both improving patient safety via directing documentation and supporting the junior doctor. Methods: Plan, Do, Study, Act (PDSA) method was used for this quality improvement project. Primary and secondary parameters were established, and baseline assessment undertaken 1 month prior to intervention with repeat data collection 1 month and 6 months after introduction of a pre-printed ward round proforma. Results: A total of 106 entries were reviewed within the 6-month study period. Pre-printed ward round proforma led to an improvement in all assessed parameters. 80% of junior doctors (n=10) and 75% nursing staff (n=8) found the pre- printed proforma standardised documentation, improving communication of plans to the wider team. Antibiotic stewardship improved from 0% (N=50) to 98% (N=30) over the 6-month period. 100% of junior doctors (n = 10) and nursing staff (n = 8) found coloured paper facilitated and bettered identification of last consultant review. Conclusion: The introduction of a pre-printed proforma allowed for standardisation of documented information for ongoing ward rounds, improved antibiotic stewardship and was received positively by junior doctors. Colour paper allowed for quicker identification of the last ward round entry which makes reviews of an unwell patient more efficient. Further work is needed to optimise and incorporate proforma within other surgical specialities.

A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit.

Background andaim Ward-round documentation is important for clinical communication and patient safety. Standardized checklists have improved ward-round documentation in surgical and medical settings. This quality improvement project aimed to introduce a standardized ward round proforma to improve documentation in a UK specialist stroke unit. Methods Ward round entries were assessed against internally agreed standardized criteria. A stroke-specific ward round proforma was designed and introduced with input from the multidisciplinary team. A repeat audit was performed, including assessment of the use of different proforma sections. Multidisciplinary team members were invited to provide feedback via an anonymous online survey. Results A total of 111 ward round entries were reviewed before the proforma was introduced. Ninety-five ward round entries were reviewed following introduction of the proforma, and 84.2% of these used the proforma for documentation. Overall documentation of standardized criteria improved from 48.7% to 62.1% with substantial improvement seen in documentation of neurological examination, presence/absence of mechanical venous thromboembolism prophylaxis, and blood test results. Multidisciplinary team feedback was positive. Conclusions The stroke-specific ward round proforma improved the quality and consistency of documentation in the unit.An updated proforma was designed using these results and multidisciplinary team feedback.

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

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.

Hertfordshire Partnership NHS Trust - Improving VTE Risk Assessments in an Older Adult Psychiatric Inpatient Unit

AimsVTE-related deaths are a leading cause of preventable mortality amongst all hospital inpatients. Psychiatric inpatients are at greater risk of this, due to administration of antipsychotic medication and longer inpatient stay. This is particularly significant during the COVID-19 pandemic, not least as it is a disease known to cause hypercoagulability, but also due to an increase in mental illness and extended admission, resulting from an overwhelmingly run social service. The objective is to analyse VTE risk assessments performed for the 23 patients at Lambourn Grove, a continuing care unit for old age psychiatric inpatients, diagnosed with dementia. The aims are to assess; the frequency at which VTE risk assessments are performed, the accuracy of each assessment and the subsequent management and appropriateness of preventative measures taken.MethodsA retrospective study was conducted of 23 service users. Data were collected from the VTE assessment form on the local electronic patient record system, and analysed to assess compliance with local guidance. GP records were consulted to cross check data and ensure accuracy of information inputted. Improvement measures include presenting at the local teaching session and implementing a mandatory monthly review onto the ward round proforma. A second cycle will be carried out to assess the success of these interventions in improving best medical practice.ResultsOf the 23 service users, 20 patients had their VTE risk assessment completed on admission and there was a delay of over a month with the remaining 3 patients. Of significance is that of all initial VTEs, 6 out of 23 contained inaccurate details, such as omission of comorbidities or a subjective assessment of mobility, indicating the need to use a standardized tool which allows for comparison across time. The mean admission duration for all 23 inpatients, as of February 2022 was calculated to be 16.2 months, with a range of 2 and 59 months. 15 patients did not have their VTE risk assessment repeated during admission, and of these 2 did have a change in their risk profile, indicating non-adherence with NICE guidelines.ConclusionThis study has identified significant areas for improvement, specifically the need for clear timing for repeated VTE assessments, consistent sources of patient's medical history and documentation of mobility status. The project has highlighted the need for a more robust VTE assessment protocol which is currently being developed, to improve patient mortality and outcomes.

50 Ward Round Documentation in Vascular Surgery – a Closed Loop Audit Cycle

Abstract Introduction Ward Rounds are a fundamental part of multidisciplinary team assessment, planning patient care and co-ordinating management decisions. Accurate documentation of patient assessment, relevant history and investigations, discussions with the patient and decisions made is crucial for continuity of patient care, medico-legally and overall patient safety. Despite the variety of record-keeping methods used throughout the NHS, it remains imperative that documentation remains accurate, contemporaneous, and can be used as a reliable source of reference throughout the patient’s journey. Method We used Royal College of Physician’s Ward Round Audit Standard 2015, with Cycle 1 of data collection from 17/5/21-23/5/21, followed by introducing interventions from 24/5/21-30/6/21. Interventions consisted of a Ward Round Proforma, displayed in each set of patient notes and communal ward areas. We completed Cycle 2 (31/5/21-6/6/21) using the same standard following which our results were analysed both individually and in respect to each other. Results Overall documentation improved by 14% across all domains from 67% to 81% following our interventions, in the 230 entries analysed (109 Cycle 2, 121 Cycle 2). Key areas included: Patient identification improving 25%, from 68% to 93%; Operation name and date improving 28% and 24% respectively and documentation of abnormal observations improving by 48%. Antibiotics and Thromboprophylaxis improved by 25% and 30% respectively, however remained under 50% in Cycle 2. Conclusions We conclude that simple, cost-effective interventions such as proformas & memory aids can significantly improve the documentation of ward rounds, thereby leading to improved patient care and safety and cohesive patient management throughout the multidisciplinary team.

EP.TU.371The introduction of standardised ward round notes in the Acute Surgical Unit

Abstract Introduction A standardised approach to note-keeping has been shown to improve patient care and experience. Aims This repeated audit cycle assesses the compliance with the introduction of a standardised proforma. Method Data collection was prospective. Round 1 (n = 83) after introduction of a ward round proforma, Round 2 (n = 94) following result analysis / education, Round 3 (n = 62) following proforma changes. Results (% Compliance with proforma) Conclusions Some improvements were seen in Round 2. A notable improvement was observed in EDD and CFD when a tick box option was implemented in Round 3. Successful implementation of a standardised note-keeping requires repeated analysis, education and modification of the proforma.

1702 A Proforma To Improve Documentation of Surgical Ward Rounds

Abstract Aim The ward round is an important vehicle in the care of surgical inpatients. Good quality documentation is essential in recording patient progress over time and communicating clearly between multidisciplinary team (MDT) members. This quality improvement project aimed to implement a standardised proforma to improve the quality of ward round documentation, improving MDT communication and patient safety. Method Ward round entries from an elective surgical unit at a District General Hospital were retrospectively reviewed using a fifteen-item checklist to assess quality of documentation. These criteria were divided into: A re-audit was performed following introduction of a ward round proforma using the same criteria. Results The pre-intervention arm included 41 entries and the post-intervention arm included 27 entries. Improvements were seen in twelve of the fifteen criteria assessed. The greatest improvements were seen in documentation of management plans; documentation of discharge plan improved from 58.5% to 100%, VTE prophylaxis from 42% to 100% and drain/ catheter plan from 42 to 93%. Documentation of two criteria (signature and bleep) decreased and documentation of date remained at 100%. Conclusions The use of a standardised proforma improves documentation of surgical ward rounds, particularly patient’s’ onward management plans. Further modifications to the proforma could aim to improve documentation of bleep and signature.

Improving risk assessments for CAMHS admissions at Great Ormond Street Hospital

AimsDuring the COVID-19 pandemic, admissions to the Mildred Creek Unit (MCU), an Inpatient CAMHS Ward at Great Ormond Street Hospital (GOSH) changed.The MCU is a 7–10 bed unit for children aged 7–15 years based on therapeutic milieu principles. The ward accepts patients via a planned national referral pathway, however, during the COVID-19 pandemic, patients were admitted as emergencies and consequently risk assessments were missed. Risk assessment is important in all admissions and as the MCU is not a locked unit, early risk assessment is particularly important.We aimed to review whether risk assessment occurred within one working day of admission, as suggested by the ward risk assessment policy, and if this was not the case, our aim was to ensure that all risk assessments took place within this period via our audit interventions.MethodWe collated data looking at the time between admission to GOSH and the date at which first risk assessments took place. We then put in place three interventions. 1)Posters prompting doctors who were providing on-call liaison input to perform a risk assessment within one working day of admission.2)New junior doctors were provided with written and verbal information to emphasise the importance of early risk assessment.3)Guidelines also highlight that assessment of risk may need to be on-going. We therefore added a prompt section in the weekly ward round proforma with the aim of reducing the interval between risk assessments during admission.The first audit cycle was conducted on the 3/8/2020 and the second on the 28/11/21 to allow for a comparative number of inpatients between the first and second audit cycle.ResultWe found these interventions significantly reduced delays in risk assessments. Prior to the audit's first cycle the average delay between admission to GOSH/MCU and a risk assessment was 2 weeks. After the interventions there were no patients whose risk assessment was delayed outside the next working day parameters.ConclusionThis full cycle audit demonstrates the impact that prompts to clinical practice can make on patient care. It is important to recognise the need for flexible risk assessment with regular review, especially at times of clinical change. We hope that this continued trend for early risk assessment leads to improved clinical care and timely discussion of risk for all new CAMHS inpatients at GOSH.

P98 Quality Improvement Project: Improving documentation and junior doctor confidence on COVID-19 ward rounds using a ward round pro forma

Introduction.Templates and checklists have improved patient outcomes in multiple settings.1,2 There are barriers in junior doctors scribing complete entries using blank sheets; patient care might suffer due to incomplete records. This project implemented a ward round pro-forma across three wards of a tertiary hospital containing high risk COVID-19 patients, aiming to improve both documentation rates and subsequent ease in finding pertinent information.Methods.Respiratory consultants determined 11 key parameters that should be documented daily for COVID-19 patients.Baseline objective data collection analysed all high-care ward round entries (n = 15), recording parameters as present or absent. Multidisciplinary team (MDT) opinions were collected via questionnaire. The pro-forma was trialled for two-weeks; repeated subjective and objective analysis was performed. All (n = 12) inpatient notes on the COVID-19 high-care ward were analysed.Results/Discussion.Pro-forma compliance was 100%. The mean number of key parameters documented per ward round entry increased by 80%, from 5 to 9. Eleven (100%) of the key parameters showed increased completion rates (fig.1). Junior doctor confidence increased 1-Likert point: ‘average’ to ‘confident’ (fig.2). 97% of respondents (n = 31) reported the pro forma saved time. Information finding and swab tracking both increased by 1-Likert point: ‘average’ to ‘easy’ (fig.2). From a medico-legal perspective, documentation of basic information (date, time) improved by 13%. This project shows not only a 60% increase in ceiling of care documentation, but also improved ease in accessing such information.Conclusion.This pro-forma is a simple and acceptable intervention to improve documentation rates and information accessibility, giving junior doctors more confidence.

Improving documentation and junior doctor confidence on COVID-19 ward rounds using a ward round pro forma

This project developed and analysed the impact of a ward round pro forma across three wards of a large tertiary hospital containing positive or high-risk COVID-19 patients. Templates and checklists have improved patient outcomes in medical, surgical and high-care settings.[1,2][1] The daily

Use of a proforma to improve documentation of the post-take ward round and encourage initiation of the comprehensive geriatric assessment in the care of the older people's service.

The post-take ward round is often the first time that a senior clinician reviews a patient on the acute medical take. Despite this, there is no official guidance regarding structure or documentation of the post-take ward round. The aim of this quality improve project was to develop a ward round proforma specifically tailored to the care of the older people's service to improve quality of documentation and to encourage initiation of the comprehensive geriatric assessment. An initial audit was carried out assessing the documentation of key information and the initiation of the comprehensive geriatric assessment during the post-take ward round. A proforma was subsequently designed and implemented with the aims of improving the quality of documentation and increasing the number of patients for whom the comprehensive geriatric assessment was started. A repeat audit was conducted to assess the effectiveness of the proforma. The results demonstrated an improvement in documentation of all key information criteria and an increase in the initiation of the comprehensive geriatric assessment. Use of a specifically tailored post-take ward round proforma improves the quality and consistency of documentation and encourages the initiation of the comprehensive geriatric assessment.

Does an Orthopedic Ward Round Pro Forma Improve Inpatient Documentation?

Thorough documentation is of utmost importance in a patient hospital experience. It forms an accurate record of an inpatient stay, facilitates handover between medical colleagues, and is also a legal document. Medical notes tend to be detailed and insightful on admission, but the daily ward round notes have often fallen short of expectation. With most patient records entered by junior level of staff, it is important to ensure that adequate documentation occurs. We analyzed notes entered in patient charts at set periods and compared them against standards set out in the Royal College of Surgeons Ireland and England, as well as Medical Council guidelines from the two countries. After this, a pro forma was established to standardize the medical record keeping on patient ward rounds. Compliance with guidelines was assessed by comparing notes before introduction of the pro forma and after their introduction. Before its introduction, 0% of notes fulfilled the full criteria selected for the pro forma documentation. After intervention, there was a good initial response, with notes capturing an average 86% of the required information. A reaudit of compliance 2 months after introduction showed a 9% decrease of information completeness to 75%. Introduction of a pro forma for the documentation of daily ward rounds improved compliance of ward round notes when compared with internationally recognized guidelines, with no additional time required during ward rounds. Despite improved compliance, continued effort is needed to achieve a better standard of care.

The post-take ward round pro forma: more than a blank space

To redesign the post-take ward round (PTWR) pro forma to improve clarity and documentation of the PTWR. We obtained feedback from multiple sources and found that the existing pro forma did not standardise documentation of the PTWR. Due to differing styles of the clinicians leading and documenting the PTWR there was a vast variation in the documentation of the PTWR. This meant that key information was not documented which was felt to have a negative impact on patient care. Given the above, we redesigned the pro forma to provide clear prompts for the junior doctor to ensure key details are documented on the …

Development of a standardised ward round proforma in a tertiary vascular surgical unit

Development of a standardised ward round proforma in a tertiary vascular surgical unit

Improving ward round standards with the use of a ­structured pro-forma

The aim of this quality improvement project was to determine whether introducing a standardised ward round pro-forma would result in improved documentation standards and increase the consideration of a number of selected areas (thromboprophylaxis, oxygen prescription, fluid status, antibiotic review, ceiling of treatment, DNACPR status, NEWS etc). A baseline audit was performed on a busy respiratory …