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P98 Quality Improvement Project: Improving documentation and junior doctor confidence on COVID-19 ward rounds using a ward round pro forma
Author(s) -
Niall Brown,
Joseph Horne,
Andrew Low
Publication year - 2021
Publication title -
bjs open
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.974
H-Index - 9
ISSN - 2474-9842
DOI - 10.1093/bjsopen/zrab032.097
Subject(s) - documentation , medicine , likert scale , pro forma , covid-19 , family medicine , medical emergency , nursing , psychology , computer science , developmental psychology , accounting , disease , pathology , infectious disease (medical specialty) , business , programming language
. Templates and checklists have improved patient outcomes in multiple settings.1,2 There are barriers in junior doctors scribing complete entries using blank sheets; patient care might suffer due to incomplete records. This project implemented a ward round pro-forma across three wards of a tertiary hospital containing high risk COVID-19 patients, aiming to improve both documentation rates and subsequent ease in finding pertinent information. Methods. Respiratory consultants determined 11 key parameters that should be documented daily for COVID-19 patients. Baseline objective data collection analysed all high-care ward round entries (n = 15), recording parameters as present or absent. Multidisciplinary team (MDT) opinions were collected via questionnaire. The pro-forma was trialled for two-weeks; repeated subjective and objective analysis was performed. All (n = 12) inpatient notes on the COVID-19 high-care ward were analysed. Results/Discussion. Pro-forma compliance was 100%. The mean number of key parameters documented per ward round entry increased by 80%, from 5 to 9. Eleven (100%) of the key parameters showed increased completion rates (fig.1). Junior doctor confidence increased 1-Likert point: ‘average’ to ‘confident’ (fig.2). 97% of respondents (n = 31) reported the pro forma saved time. Information finding and swab tracking both increased by 1-Likert point: ‘average’ to ‘easy’ (fig.2). From a medico-legal perspective, documentation of basic information (date, time) improved by 13%. This project shows not only a 60% increase in ceiling of care documentation, but also improved ease in accessing such information. Conclusion. This pro-forma is a simple and acceptable intervention to improve documentation rates and information accessibility, giving junior doctors more confidence.

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