ThP6.17 - ‘If it’s not documented, it didn’t happen’: an audit into surgical ward documentation and clinicians expectations in a district general hospital

Abstract Introduction & Aims There are guidelines published by the Royal College of Surgeons (RCS) on adult surgical ward round documentation. Locally, documentation is done on pre populated sheets containing blood results, antibiotics and VTE prophylaxis. We aimed to assess documentation in our unit against the RCS guidelines. Methodology We audited documentation for surgical inpatients over 1 week, looking at daily ward rounds (DWR), and initial consultant post take ward round (PTWR). Through an online survey, we established the minimum standards of documentation expected by doctors of varying seniority on a ward round within our unit. Results 21 DWR and 21 PTWR entries were reviewed; 90% (n=19) contained the date and 95% (n=20) the name of the reviewing consultant. Time of review was documented in 29% (n=6) and 35% (n=7) respectively. 33% (n=4) DWR entries documented examination findings, compared to 8 40% (n=8) PTWR entries. 45% (n=10) PTWR contained the presenting complaint. 26 doctors completed the online survey; 100% thought date, time and examination findings were important. More senior doctors highlighted that drain status was a key part of ward round documentation. Conclusions Within our unit, there is poor adherence with the RCS ward round documentation guidelines. Juniors suggested this is because ward rounds are too fast paced, often on complex and comorbid patients. We plan to address our findings with an improved surgical admission proforma and an electronic handover to ensure all team members are up to date with patients’ admission details.