Improving the consultant ward round: implementing a standardised ward round pro forma

Ketan Patel; Neel Sharma; Sarah Baron

doi:10.7861/futurehosp.2-2-s1

Aims

To provide a standardised consultant ward round pro forma to improve patient safety through clear documentation and to assist medical and nursing teams when reviewing the patient health record.

Methods

A pilot pro forma to make consultant ward round entries clear, and provide crucial information easily to on-call teams and the MDT, was designed and implemented for a 2-month period on a general medical ward. The use of the pro forma was evaluated with a questionnaire to receive feedback from the MDT and redesigned based on the feedback.

We repeated the pilot using the redesigned pro forma and audited its use and compared it with traditional documentation of the consultant ward round.

The comparison was made during a 1-week period between six consultants, of which three used the pro forma and three used traditional documentation. Each consultant ward round entry was scored against the documentation of these variables: ‘patient details’, ‘date and time’, ‘diagnosis/impression’, ‘ceiling of treatment’ and ‘identifiable author’.

Results

A total of 46 ward round entries were made using the pro forma and 30 using traditional documentation. The average attainment of the variables measured in ward round recorded using the pro forma was 96% and that of those recorded using traditional documentation was 64%.

Traditional documentation failed mostly on documentation of patient details and ceiling of treatment, with only 50% attainment of documented patient details and 10% attainment of documented ceiling of treatment.

Conclusions

In conclusion, our recommendation is to implement the use of a standardised form to record the consultant ward round. This would ensure that important details are documented to ensure better patient safety through clear documentation and improved concordance with current RCP recommendations regarding record-keeping during medical ward rounds.