Introducing a standardised ward round proforma for dental core trainees in Oral and Maxillofacial Surgery: A closed loop audit

Oral and Maxillofacial Surgery (OMFS) services in the UK commonly rely on dental core trainees (DCTs) to document ward rounds, despite many having limited prior experience in hospital or ward-based settings. Ward rounds are often fast-paced environments increasing the risk of incomplete or inaccurate documentation. This can compromise patient safety leading to mistakes or near-misses. Whilst safety checklists are recommended by national bodies such as the Royal College of Physicians and Royal College of Nursing, there is limited guidance and structured documentation tools for OMFS ward rounds to support DCTs. To evaluate the impact of an OMFS-specific ward round proforma on the quality and completeness of ward round documentation amongst DCTs. A closed-loop audit was conducted at St Richard’s Hospital, Chichester, UK. Thirty ward round entries prior to proforma introduction (cycle 1) were compared with thirty entries following implementation (cycle 2). Documentation was assessed against predetermined key categories based on national guidance and consultant feedback. Data were analysed using descriptive statistics and Pearson’s chi-square test to determine statistical significance of results. Cycle 1 demonstrated deficiencies in documentation, particularly in patient safety parameters. Following introduction of the proforma, there were improvements across nearly all domains. Statistically significant improvements were observed in most categories. Many safety elements improved from low baseline values to over 85% compliance. A structured ward round OMFS proforma substantially improved documentation standards and enhanced patient care. This is particularly valuable for DCTs with limited ward round experience, acting as an educational documentation tool.