Standardizing Best Practices: An Initiative Utilizing Surgical Ward Round Checklists to Enhance Patient Safety and Documentation in Our Trust

<b>Aims/Background</b> Comprehensive ward round documentation is crucial for ensuring effective communication and patient safety. Standardized checklists have been shown to improve documentation quality in various healthcare settings. This article presents the findings of a comprehensive audit consisting of two cycles, which incorporate feedback, bring about implications, and evaluate the impact of a standardized proforma on inpatient ward round documentation for General Surgery patients in a high-volume surgical unit. <b>Methods</b> Initially, a staff survey was conducted to identify deficiencies in ward round documentation, highlighting the need for a standardized proforma. To establish a baseline, a retrospective review of 45 ward round entries assessed five key areas: diagnosis, disease management, objective assessments, discharge planning, and documentation logistics. Subsequently, within a month of implementing the changes, 20 ward round entries were analyzed based on the same criteria during a second cycle. <b>Results</b> During Cycle 1, we found that 95.6% of the notes lacked information on Venous thromboembolism (VTE) prophylaxis, while nearly 88.9% were missing data on current issues, and 46.7% did not include pain scores. Additionally, we found that bowel function and fluid balance information were absent in 62.2% and 95.6% of ward round entries, respectively. Cycle 2 showed a significant improvement in terms of documentation for most of the items. Most of the variables were documented in all the reviewed proformas and others such as VTE prophylaxis and fluid balance showed a significant improvement being documented in 95% of the proformas. <b>Conclusion</b> Employing a standardized ward round proforma demonstrably improved documentation completeness across all safety parameters within our surgical unit. This enhanced focus on crucial safety discussions during ward rounds is expected to further elevate patient safety outcomes.