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Does an Orthopedic Ward Round Pro Forma Improve Inpatient Documentation?
Danilo Vukanic1, Enda G Kelly, Susan May Cleary
1From the Department of Trauma and Orthopaedic Surgery, University Hospital Waterford.
Journal of Patient Safety
|March 14, 2020
Summary
Implementing a standardized pro forma significantly improved inpatient medical record documentation. While initial compliance was high, ongoing efforts are necessary to maintain and enhance the quality of patient care documentation.
Area of Science:
- Medical Documentation
- Healthcare Quality Improvement
- Clinical Record Keeping
Background:
- Thorough patient documentation is critical for accurate medical records, seamless handovers, and legal protection.
- Daily ward round notes often lack the expected detail and completeness.
- Ensuring adequate documentation is crucial, especially with junior staff input.
Purpose of the Study:
- To assess the impact of a standardized pro forma on the quality of daily ward round documentation.
- To compare documentation compliance against established national and international guidelines.
Main Methods:
- Patient chart notes were analyzed at set intervals.
- A pro forma was developed to standardize ward round record keeping.
- Compliance was measured by comparing notes before and after pro forma implementation.
Main Results:
- Initially, 0% of notes met the full documentation criteria before the pro forma.
- After pro forma introduction, documentation completeness averaged 86%.
- A 2-month follow-up audit showed a decrease in completeness to 75%.
Conclusions:
- A pro forma effectively improved compliance with ward round documentation guidelines.
- No additional time was required for ward rounds with the pro forma.
- Sustained efforts are needed to further elevate the standard of patient care documentation.
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