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.