ThTP3.2 Introducing a ward round template to improve the quality of documentation on the general surgery ward round
Matthew Davenport, Chetying Chan, Shameel Suhail, Emma Davies- Surgery
Abstract
Aims
We aimed to improve documentation on general surgical ward rounds, through the introduction of a ward round template at a single UK surgical unit.
Methods
The structure of the template was adapted from the ‘Surgical Assessment for Emergencies Ward Round Tool’ produced by the RCSEd, with modifications based on local requirements. A retrospective audit was performed of 4 weeks of electronic ward round notes prior to, and 4 weeks after the introduction of the template. Ward round notes on 2 chosen days (Wednesdays and Saturdays) during the 4 week study periods were included for analysis. We observed how frequently specific important clinical information was documented.
Results
378 electronic ward round notes were analysed (176 before, and 202 after the introduction of the template). The ward round template was used, either in part or in full, in 72% of ward round notes following it’s introduction. An pre-existing structured electronic ward round note had previously been used in only 1% of cases. How frequently each of the following components was documented when using the template was: important admission events (86%), VTE prophylaxis (93%), nutritional status (76%), review of prescribed antibiotics (91%) and ceiling of care (65%). We demonstrated statistically significant improvements for each of these components (p<0.05) from pre-template rates (73%, 16%, 63%, 51% and 2% respectively).
Conclusion
The introduction of a ward round template vastly improved the frequency with which a structured approach to ward round was taken. In doing so, significantly improving the documentation of important clinical information.