HPB SO63 - A Closed-Loop Audit on Surgical Ward Round Documentation in a Tertiary Hospital

Abstract Background Surgical ward rounds play a pivotal role in overall patient outcome during surgical and perioperative care. Clear and comprehensive documentations are crucial in providing an accurate account of ward round activities. We aimed to assess the quality of hepatopancreatobiliary (HPB) ward round documentation and the impact of a HPB surgical ward round proforma on the quality of documentation. Method 50 medical notes were reviewed in a tertiary centre to determine if key components of ward round documentation such as the date, time, diagnosis, procedure, consultant, person documenting, information communicated to patient, observations, investigations and management plan were documented. A proforma for ward round documentation was introduced. A re-audit was performed to review the impact of a proforma on ward-round documentation. Results The time of ward round, relevant history, NEWS and management plan were recorded in more than 50% of medical notes. However, the diagnosis, consultant, person documenting, information communicated to patient, wound review, medication review, fluid balance, investigations, follow up and discharge plans were documented in less than 50% of medical notes. After the introduction of a proforma, the date and time of the surgical ward round were documented in 94% of medical notes. 84% had initials of the consultants leading ward-rounds and the person documenting. More than 80% notes included relevant examination, information communicated to patient, wound and medications review. Conclusion Surgical ward round proformas have a role in improving ward round documentation. Good record keeping is essential for continuity of care, optimising quality of care and ensuring patient safety.