Background Surgical ward round documentation, essential for high-quality patient care, is often completed poorly. The advent of electronic medical records offers an opportunity to introduce proformas, aiding junior staff in completing notes both timely and accurately. We aimed to assess whether the introduction of a proforma would improve the quality and speed of ward round documentation. Methods We completed a prospective cohort analysis of ward round documentation at a single institution. Analysis was conducted on the documentation of a single surgical team over a 10-week period, comprising five weeks of baseline data collection followed by five weeks with implementation of a proforma. This proforma was based on the "David & Wendy" acronym, encompassing diet, activity, vital signs, investigations/IV therapy, drains/lines, wound assessment, examination findings, nursing concerns, drugs/deep vein thrombosis (DVT) prophylaxis, and barriers to discharge. Results A total of 711 ward round notes were analyzed, 349 with proforma and 362 without. Statistically significant improvements were observed in the documentation of diet, activity, investigations/IV therapy, drains/lines, wound assessment, nursing concerns, drugs/DVT prophylaxis, and barriers to discharge (p < 0.05) with proforma use. No significant difference was noted in the documentation of vital signs or examination findings. The time taken to finalize ward round notes was significantly reduced with the proforma (M = 31.28 vs. 60.05 minutes, p < 0.001). Conclusion The introduction of the David & Wendy proforma significantly improved the speed and quality of documentation for key surgical ward round information during our study.
Keywords: checklist; documentation; general surgery; quality improvement; surgery.
Copyright © 2023, Taylor et al.