Does an Orthopedic Ward Round Pro Forma Improve Inpatient Documentation?

ABSTRACT

INTRODUCTION: 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. METHODS: 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. RESULTS: 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%. CONCLUSIONS: 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.