This document summarizes a ward round documentation audit conducted over 8 weeks. The results showed substandard documentation across several categories assessed. Discussion notes that poor documentation can negatively impact patient safety and care continuity. While electronic documentation may be ideal, pragmatic first steps include education, improving note access, utilizing ward round checklists, and addressing time pressures faced by junior doctors. The conclusion is that a multidisciplinary team approach is needed to implement stepwise improvements to documentation standards.

1. Conrad Lee, CT2
July 2014- Sep 2014
T&O, BSUH
Wardround documentation audit
June - Aug 2014

2. Section 1: Background
Background Aims /Method Results Discussion Conclusion

3. Current literature / guidelines
Why is good documentation
important?
• Support safe and
effective patient care
• Medical-legal

4. Current literature / guidelines
Documentation in
wardrounds
• Crucial part in continuity of
patient’s care.
• Written communication to
colleagues

5. Current literature / guidelines
“You must keep
clear, accurate and
legible records”
- GMC Good Medical Practice 2013

6. Current literature / guidelines
Current Standards / guidelines
- Health informatics Unit, Royal College of
Physicans, April 2008
“The standards should be
used for all hospital
patient records”

7. Current literature / guidelines
But it’s not always
that simple ...
• Time pressure
• Accessibility of notes
• Number of staff on the round
• Staff experience
• Who is leading the round

8. BackgroundBackground
Section 2: Aims & Method
Aims /Method Results Discussion Conclusion

9. Aims:
1. Assess our current standards of wardround documentations
2. Compare current practise with best practice guidelines
3. Explore and suggest ways to improve current practice
4. Define an agreed action plan and implement improvement changes

10. Methods:
• Concurrent observational study
• 8 weeks – 23rd June to 17th Aug
• Exclusions: paediatric, orthogeri
• Random selection of wardround entries
Variables
1. Wardround details
2. Clinical details
3. Management and
Investigations
4. Clinical assessment
5. Management plan
6. Documenting doctor

11. 86%
11.60%
12.70%
42.30%
92%
62.80%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Wardround details
Clinical details
Management and investigations
Clinical assessment
Management plan
Documenting doctor
On average

12. Section 1: Background
BackgroundBackgroundBackground
Section 3: Results
Aims /Method Results Discussion Conclusion

13. Results:
74 wardround entries reviewed
• 9 weekend entries
• 7 outliers
57
3
12
2
lower limb
polytrauma
spine
upper limb

14. P.T.O…
Wardround details
96%
97%
86%
66%
0% 20% 40% 60% 80% 100%
Name of consultant leading wardround
Entry date
Entry time
Patient identification
% documented

15. P.T.O…
Clinical details
34%
1%
5%
18%
0%
0% 20% 40% 60% 80% 100%
Active issues
Resus status
Sig PMH
Diagnosis
Admission date
% documented

16. P.T.O…
Management and investigations
5%
9%
24%
0% 20% 40% 60% 80% 100%
Radiology report
lab results
Management undertaken
% documented

17. P.T.O…
Clinical assessment
34%
35%
62%
38%
0% 20% 40% 60% 80% 100%
Clinical impression
Discussion with patient
Observations
Examination findings
% documented
48%
38%
14%
obs stable apyrexia (n=36)
not documented (n=28)
actual obs reading (n=10)

18. P.T.O…
Management plan
19%
14%
92%
0% 20% 40% 60% 80% 100%
Dicharge plans
weightbearing status*
Ongoing managment plan
% documented

19. P.T.O…
Documenting doctor
70%
45%
82%
54%
0% 20% 40% 60% 80% 100%
contact bleep
grade
signature
name of doctor
% documented

20. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Wardround details
Clinical details
Management and investigations
Clinical assessment
Management plan
Documenting doctor
On average

21. Section 1: Background
BackgroundBackground
Section 4: Discussion
Aims /Method Results Discussion Conclusion

22. Yeah.. The results are pretty poor, so
what?
Wardrounds have always been like this
and it has worked “fine”, why change
now and create hassle???

24. We should not just look at the figures,
but focus on why good documentation
is really important for ours patients and
staff.

25. Who are the stake holders?

26. Example scenario:

27. What is in the literature?
checklists / proforma Electronic wardrounds

28. Proformas
4) Using a proforma to improve standards of documentation of
an orthopaedic post-take ward round
- BMJ Qual Improv Report. 2013
2) Do post-take ward round proformas improve communication
and influence quality of patient care?
- Postgrad Med J. Nov 2004
3) A Considerative Checklist to ensure safe daily patient review
- The Clinical Teacher. August 2013
1) Why patients need leaders: introducing a ward safety checklist
- J R Soc Med. September 2012

29. Proformas
BSUH Surgical department – wardround proforma
Initial resistance from consultants and some registrars,
but highly favoured by junior doctors and nursing staff
6 week reaudit showed improved documentation
Proforma to be made more user friendly
limiting factors to complete documentation
- Time pressure
- Variability between juniors

31. Proformas
Pros Cons
Improve standard of documentation
Better written communication
Promote patient safety
Educational value for students
More sheets of paper
?longer wardrounds
We don’t know unless we try

32. Electronic wardrounds

33. Electronic wardrounds
Birmingham Women’s Hospital’s neonatal unit, 2013
• Wardround with portable laptop
• Self-programmed wardround spreadsheets,
prepopulated lists, can be wirelessly printed
• Reduction of WR time from 5 hours to 4 hours
• Improved documentation (100% legible) and
handover standards

34. Electronic wardrounds
“There were a lot of staff who
were sceptical and the NHS is
set in its ways. I believe the
system we developed could be
of benefit to everywhere that
does an in-patient ward round.”
- Dr Sarah Steadman

35. Electronic wardrounds
ELECTRONIC WARDROUNDS!?
Sounds like a distant future for us at BUSH…

36. Electronic wardround:

37. Pragmatic solutions:
1. Education
2. Improve ease of patient note access and navigation
3. MDT wardrounds
4. Wardround “checkers”
5. Be conscientious of the limits of juniors (a human being)
6. Proformas
7. Electronic wardround

38. BackgroundBackground
Section 5: Conclusion
Aims /Method Results Discussion Conclusion

39. • Wardround documentations are substandard
• Causes of poor documentation is multifactorial, but can
be improved
• We should aim for EMR, but we need to take small steps
by step improvements to reach this using a MDT
approach
Conclusion:

40. Action plan

41. References
• Why patients need leaders: introducing a ward safety checklist - J R Soc Med. September 2012
• Do post-take ward round proformas improve communication and influence quality of patient
care? - Postgrad Med J. Nov 2004
• A Considerative Checklist to ensure safe daily patient review - The Clinical Teacher. August 2013
• Using a proforma to improve standards of documentation of an orthopaedic post-take ward
round - BMJ Qual Improv Report. 2013
• Electronic Ward Rounds and #HandoverProject – improving quality while increasing efficiency -
Arch Dis Child 2014
Background Aims /Method Results Discussion Conclusion