Improving Urology Ward Round Documentation Through Sequential Digital Interventions: A Three-Cycle Quality Improvement Project

Introduction Complete ward round documentation is essential for safe and effective clinical decision-making, continuity of care, and multidisciplinary communication. Concerns around the completeness and accessibility of handwritten ward round entries in a urology department of a tertiary centre prompted a clinical audit, which identified omissions in notes. This quality improvement project evaluated changes in ward round documentation completeness across sequential audit periods following the introduction of electronic free-text documentation and subsequently a structured electronic proforma, using standards adapted from the Royal College of Surgeons of Edinburgh SHINE Surgical Ward Round Toolkit. Methods The project consisted of successive audit and intervention cycles. Ward round entries were assessed for 11 documentation criteria and coded as documented, not documented, or not applicable. Baseline data were collected from handwritten documentation from December 2024 to April 2025 (n = 32). Electronic free-text ward round documentation was then implemented, and these notes were re-audited from January 2026 to May 2026 (n = 43). Following this, an electronic proforma was launched, and a third audit of notes in the post-proforma implementation period was completed from June 2026 to July 2026 (n = 50), assessing both proforma and continued free-text ward round entries. The primary outcome was per-entry completeness, calculated as documented applicable criteria divided by all applicable criteria. Aggregate compliance was reported descriptively. Results Documentation completeness was progressively higher across the three sequential audit periods. Median per-entry completeness increased from 27.3% with paper documentation, to 50% with electronic free-text documentation, and to 60% in the post-proforma implementation period. Aggregate compliance increased from 29.2% to 48.3% and 59.3%, respectively. The proforma was used in 26 out of 50 (52%) post-implementation entries. Proforma entries had a higher median completeness than contemporaneous free-text notes (63.6% vs. 55.1%). Conclusions Structured ward round templates and interventions are known to improve the quality of ward round documentation. This quality improvement project saw ward round documentation completeness increase across sequential audit periods. Future work should address barriers to proforma adoption and target persistently under-documented criteria.