Comprehensive and timely documentation on orthopedic ward rounds continues to be problematic, leading to delayed or inappropriate patient care and miscommunication between health care providers. The authors introduced a simple checklist to improve the documentation on orthopedic ward rounds in their institution. A prospective cohort study was performed. Standard care was provided for cohort A. During a 2-week period, the documentation of patient care by physicians following a ward round was assessed in terms of venous thromboembolism prophylaxis, fasting status, wound or dressing plan, weight-bearing status, and important surgical details. The physicians were blinded to this initial review. For cohort B, a structured ward round checklist was introduced during a 2-week period. A total of 132 patient encounters were recorded in cohort A. Important issues that were rarely discussed included vital signs (11.4%), venous thromboembolism prophylaxis (9.8%), and bowel status (3.8%). Issues that were poorly documented included fasting status (9.1%), wound or dressing plan (6.8%), and weight-bearing status (11.4%). After introduction of the checklist, daily documentation of surgical details improved from 38.6% to 85.3% of patient encounters. Fasting status documentation improved from 9.1% to 70.6% of patient encounters. Venous thromboembolism prophylaxis discussion increased from 9.8% to 45.6% of the time, while its documentation improved from 6.8% to 92.6%. Documentation of weight-bearing status improved from 11.4% to 83.8% (all P<.0001). The use of a structured checklist during orthopedic ward rounds led to significant improvement in both the consideration and the documentation of key aspects of surgical care. [Orthopedics. 2017; 40(4):e663-e667.].
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