一般外科病棟回診記録における医師の詳細と時間の正確な記録の評価：監査と再監査

Background Accurate medical documentation is essential for patient safety, continuity of care, and medico-legal accountability. Incomplete or inconsistent entries can compromise communication within the multidisciplinary team and expose healthcare providers to legal risk. This audit assessed compliance of general surgery ward round documentation with General Medical Council (GMC), Royal College of Surgeons, and local Trust standards, focusing on the inclusion of the date, time, clinician's full name, signature, and GMC number. Methodology The audit was conducted across three general surgery wards at Broomfield Hospital. The initial audit data were collected on March 27-28, 2025, and the re-audit data were collected on June 26-27, 2025, three months later. Ward round notes were reviewed for compliance with the following five key parameters: date, time, full name, signature, and GMC number. Following presentation of the initial findings, targeted interventions were implemented, including educational posters, email reminders, and encouragement for doctors to use personal stamps. Data were analysed using Microsoft Excel, and chi-squared testing was used to determine statistical significance at p-values <0.05. Results In total, 83 ward round notes were analysed in the initial audit cycle and 92 in the re-audit. Compliance improved across all parameters, i.e., date (100%), time (27.7%→90.2%), full name (67.5%→87.0%), signature (72.3%→94.6%), and GMC number (12.0%→75.0%), with statistically significant improvements in all except the date parameter (p < 0.05). Conclusions Targeted awareness and educational interventions significantly improved adherence to documentation standards within the general surgery department. These measures enhanced record-keeping accuracy, improved professional accountability, and may help reduce medico-legal risk and associated financial costs to the Trust.