Related Experiment Video
Updated: Apr 2, 2026

Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients
Published on: July 12, 2024
Improving ward round documentation using the Heidi Health application
Amna Qamar1, Mairead Kelly2, Robert Maweni2
1Oxford University Hospitals NHS Foundation Trust, Oxford, England, UK amna.qamar3@nhs.net.
Introduction:
Accurate and timely documentation during surgical ward rounds is critical for ensuring patient safety, effective multidisciplinary communication and continuity of care. In high-demand surgical settings, resident doctors often experience delays in completing documentation due to competing clinical priorities. This quality improvement project aimed to assess whether an artificial intelligence (AI) transcription tool, Heidi, could reduce documentation time in a busy ear, nose and throat (ENT) department within a tertiary centre.
Methods:
Baseline data on time taken to complete conventional ward round documentation were collected over a 4-day period. The Heidi AI tool was then implemented to transcribe real-time discussions during ward rounds and automatically format the information using a structured template adapted from the SHINE Surgical Ward Round Toolkit. Documentation times using the AI system were recorded over a subsequent 4-day period.
Results:
The implementation of Heidi led to a statistically significant reduction in documentation time compared with conventional methods.
Conclusions:
Using AI tools can not only improve timeliness of clinical records but also free resident doctors from scribing duties, allowing greater participation in patient care and enhancing educational opportunities. This intervention demonstrated the potential of AI-assisted documentation to improve workflow efficiency and patient flow while supporting resident doctor training and reducing administrative burden in a surgical setting.
Related Concept Videos
Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Legal Guidelines for Documentation
Methods of Documentation V: CBE
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
Flow Sheet
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...

