A Standardised Clerking Proforma Improves the Perceived Satisfaction of Healthcare Professionals and Leads to Better Documentation

Introduction High-quality medical records are integral to Good Medical Practice and providing optimal patient care in the United Kingdom. This study was designed to assess the effectiveness of a structured Surgical Assessment Proforma in improving documentation within the surgical assessment unit (SAU) of a major trauma centre. Methodology A four-phase prospective study was undertaken using the Plan, Design, Study, and Act (PDSA) methodology. This included an initial clinician survey and proforma development, audit, re-audit post-implementation, and a final user survey. Evaluation and proforma design utilised standards from the Royal College of Surgeons and the Professional Record Standards Body (PRSB). Notes of all patients admitted to the SAU, over two separate one-week periods, were assessed for the completeness of documentation by two independent doctors. Statistical analysis employed a t-test assuming unequal variance, with a p-value of <0.05 considered significant. The study was considered a service evaluation and was exempt from ethical approval. Results During the pre-proforma survey, 100% of respondents felt a proforma would be beneficial, and 77% believed key elements of clerking are missed with the current system. During Cycle 1 (n=62), absence of information was noted in the categories of Responsible Consultant, Medication History, Allergy Status, and Differential Diagnosis. During Cycle 2 (n=119), of 45 assessment criteria, 38 improved (23 significantly; p<0.05), two showed no change, and five were reduced (two significantly; p<0.05). Documentation rates in nine categories improved by over 50%. During the post-proforma survey, 73% of doctors and 86% of allied healthcare professionals (AHPs) agreed that documentation improved with proforma use. Sixty-six percent of clinicians agreed that proformas reduced omission of essential information and provided safe clerking guidance for doctors. One hundred percent of AHPs agreed that the proforma improved handover between shifts. Conclusion In a major trauma centre, a standardised proforma improves the completeness of clerking and improves documentation. It also improves the perceived satisfaction of the clinicians and AHPs. The standardised proforma still has a role until the electronic records are implemented.