Improving ward round standards with the use of a ­structured pro-forma

S McNeill; D Kumar; M O’Neill; C King; F McBride; C Butler

doi:10.7861/futurehosp.4-2-s21

Aims

The aim of this quality improvement project was to determine whether introducing a standardised ward round pro-forma would result in improved documentation standards and increase the consideration of a number of selected areas (thromboprophylaxis, oxygen prescription, fluid status, antibiotic review, ceiling of treatment, DNACPR status, NEWS etc).

Methods

A baseline audit was performed on a busy respiratory ward for three weeks prior to pro-forma implementation. Case notes were examined and data collected for documentation standards and consideration of the pre-defined areas listed above. After implementation, the same data was collected weekly.

Results

Compliance with the pro-forma has risen from 70% to 85%. When all measures are collated, there wass an overall improvement in the standards of documentation and the consideration of the aforementioned selected areas from 49% to 89%. Specific areas such as clear patient / doctor identification, date and time, thromboprophylaxis, NEWS assessment and oxygen prescription are now consistently 100%.

Conclusions

Lack of document standardisation can compromise the quality of medical record keeping, promote significant variation, and have an impact on handover and continuity of care. Busy clinical staff, working in highly pressured environments, are more likely to overlook important issues or make errors/omissions that can impact on patient experience, safety or clinical outcome.

Data collected to date would support the use of our ward round pro-forma as a means to limit this variability in documentation standards. It has also served to minimise the number of issues being overlooked, and has been hailed as a tool that promotes good continuity of care and handover. We plan to implement the Pro-forma into further champion wards to determine if these results can be replicated and to measure the impact on length of stay.