Completeness in clerking: The surgical admissions proforma

Area of Science:

• Medical Informatics
• Surgical Patient Care
• Clinical Documentation Improvement

Background:

• Patient data accessibility is critical for surgical safety, relying on effective clerking and handovers.
• This study evaluated a surgical clerking proforma's impact on information recording at Northwick Park Hospital's Surgical Admissions Unit (SAU).

Purpose of the Study:

• To assess the effectiveness of a surgical clerking proforma in improving patient data documentation.
• To evaluate the impact of the proforma on the accessibility and coherency of patient notes for healthcare professionals.

Main Methods:

• Two surveys were conducted over 5 days to assess patient notes before and after proforma implementation.
• The first survey audited 28 pre-proforma and 23 post-proforma patient notes against 17 Royal College of Surgeons criteria.
• The second survey questioned 25 pre-proforma and 17 post-proforma healthcare professionals on data accessibility and note coherency.

Main Results:

• Five of the 17 documented criteria showed significant improvement post-proforma (p < 0.01 for height and occupation; p < 0.05 for medication history, weight, and investigations).
• Fewer healthcare professionals needed to revisit archived notes after proforma implementation (p < 0.05).

Conclusions:

• A comprehensive surgical clerking proforma enhances patient data documentation and saves clinician time compared to traditional methods.
• Successful implementation offers a reliable platform for future clinical audits and improved patient safety.