347 General Surgery Ward Round Documentation: A Quality Improvement Project

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.