A quality improvement project using a problem based post take ward round proforma based on the SOAP acronym to improve documentation in acute surgical receiving

TY - JOUR

T1 - A quality improvement project using a problem based post take ward round proforma based on the SOAP acronym to improve documentation in acute surgical receiving

AU - Dolan, R.

AU - Broadbent, P.

N1 - Publisher Copyright: © 2015 The Authors.

PY - 2016/2/1

Y1 - 2016/2/1

N2 - Objectives: Ward round documentation provides one of the most important means of communication between healthcare professionals. We aimed to establish if the use of a problem based standardised proforma can improve documentation in acute surgical receiving. Methods: Gold standards were established using the RCSE record keeping guidelines. We audited documentation for seven days using the following headings: patient name/identification number, subjective findings, objective findings, clinical impression/diagnosis, plan, diet status, discharge decision, discharge planning, signature, and grade. After the initial audit cycle, a ward round proforma was introduced using the above headings and re-audited over a seven day period. Results: The pre-intervention arm contained 50 patients and the post intervention arm contained 47. The following headings showed an improvement in documentation compliance to 100%: patient name/identification number vs 96%, subjective findings vs 84%, objective findings vs 48%, plan vs 98%, signature vs 96%, and grade vs 62%. Documentation of the clinical impression/diagnosis improved to 98% vs 30%, diet status rose to 83% vs 16%, discharge decision to 66% vs 16%, and discharge planning to 40% vs 20%.Conclusions: Standardised proformas improve the documentation of post-take ward round notes. This helps to clarify the onward management plan for all aspects of a patient's care and will help avoid adverse events and litigation. This should improve the quality and safety of Patient Care.

AB - Objectives: Ward round documentation provides one of the most important means of communication between healthcare professionals. We aimed to establish if the use of a problem based standardised proforma can improve documentation in acute surgical receiving. Methods: Gold standards were established using the RCSE record keeping guidelines. We audited documentation for seven days using the following headings: patient name/identification number, subjective findings, objective findings, clinical impression/diagnosis, plan, diet status, discharge decision, discharge planning, signature, and grade. After the initial audit cycle, a ward round proforma was introduced using the above headings and re-audited over a seven day period. Results: The pre-intervention arm contained 50 patients and the post intervention arm contained 47. The following headings showed an improvement in documentation compliance to 100%: patient name/identification number vs 96%, subjective findings vs 84%, objective findings vs 48%, plan vs 98%, signature vs 96%, and grade vs 62%. Documentation of the clinical impression/diagnosis improved to 98% vs 30%, diet status rose to 83% vs 16%, discharge decision to 66% vs 16%, and discharge planning to 40% vs 20%.Conclusions: Standardised proformas improve the documentation of post-take ward round notes. This helps to clarify the onward management plan for all aspects of a patient's care and will help avoid adverse events and litigation. This should improve the quality and safety of Patient Care.

KW - Audit

KW - Documentation

KW - Proforma

KW - Quality improvement

KW - SOAP acronym

KW - Surgical receiving

UR - https://www.scopus.com/pages/publications/84951018243

U2 - 10.1016/j.amsu.2015.11.011

DO - 10.1016/j.amsu.2015.11.011

M3 - Article

AN - SCOPUS:84951018243

SN - 2049-0801

VL - 5

SP - 45

EP - 48

JO - Annals of Medicine and Surgery

JF - Annals of Medicine and Surgery

ER -