Improving Clinical Workflows: A Quality Improvement Project on Admission Documentation Standardization.

Area of Science:

• Medical Informatics
• Healthcare Quality Improvement
• Surgical Patient Care

Background:

• Complete admission notes are crucial for patient safety and care continuity in surgical settings.
• A baseline audit revealed significant omissions in surgical admission records, including History of Presenting Illness (HOPI) and Past Medical History (PMH).
• Existing documentation practices were insufficient, necessitating an intervention to improve record completeness.

Purpose of the Study:

• To assess the impact of a standardized admission proforma on the completeness of surgical admission notes.
• To identify key areas for improvement in medical documentation through iterative refinement of a proforma.
• To enhance patient safety and care continuity by optimizing admission record quality.

Main Methods:

• Two Plan-Do-Study-Act (P.D.S.A.) cycles were conducted between April-May 2025.
• A standardized admission proforma was iteratively implemented and refined based on user feedback.
• Chart reviews of 40 surgical admission notes were performed at baseline, after Cycle 1, and after Cycle 2 to assess documentation completeness of specific fields.

Main Results:

• Following Cycle 1, History of Presenting Illness (HOPI) documentation improved to 100%, and Examination findings to 97.5%.
• After Cycle 2, Past Medical History (PMH) improved significantly to 85% (p<0.001), and Visual Aid documentation rose to 75% (p=0.022).
• Documentation for Investigations and Management Plan remained at 100% throughout the study.

Conclusions:

• Iterative implementation of a structured admission proforma effectively enhanced the completeness of surgical admission notes.
• Standardized templates are a reliable tool for improving medical documentation quality in surgical settings.
• The findings support the broad adoption of standardized proformas to improve surgical admission record keeping and patient care.