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Value of an orthopaedic admission proforma
Munzir Akasha1, Oliver Boughton2, May Cleary2,3
1Orthopaedics, University Hospital Waterford, Waterford, Ireland munzir@live.com.
Background:
Admission notes are an important aspect of clinical practice and a vital means of communication among healthcare professionals. Incomplete or poor clinical documentation on admission can lead to delayed surgery.
Patients And Methods:
A retrospective analysis of 20 consecutive admission notes to our department was compared against the Royal College of Surgeons standards (GSP 2014). A new admission proforma was designed, and after the introductory period, two further retrospective cycles were performed.
Results:
In total, 60 admission notes were analysed. Following the introduction of the proforma, there was an overall improvement in the documentation of the quality and quantity of notes studied.
Conclusion:
Our study demonstrated that a well-structured admission protocol can improve the overall quality of admission notes.
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