Wardround documentation audit
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Transcript of Wardround documentation audit
Conrad Lee, CT2
July 2014- Sep 2014
T&O, BSUH
Wardround documentation auditJune - Aug 2014
Section 1: Background
Background Aims /Method Results Discussion Conclusion
Current literature / guidelines
Why is good documentation important?
• Support safe and effective patient care
• Medical-legal
Current literature / guidelines
Documentation in wardrounds
• Crucial part in continuity of patient’s care.
• Written communication to colleagues
Current literature / guidelines
“You must keep clear, accurate and legible records”
- GMC Good Medical Practice 2013
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”
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
BackgroundBackground
Section 2: Aims & Method
Aims /Method Results Discussion Conclusion
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
Methods:
• Concurrent observational study
• 8 weeks – 23rd June to 17th Aug
• Exclusions: paediatric, orthogeri
• Random selection of wardround entries
Variables 1. Wardround details2. Clinical details3. Management and
Investigations 4. Clinical assessment 5. Management plan 6. Documenting doctor
Wardround details
Clinical details
Management and investigations
Clinical assessment
Management plan
Documenting doctor
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
86.00%
11.60%
12.70%
42.30%
92.00%
62.80%
On average
Section 1: Background
BackgroundBackgroundBackground
Section 3: Results
Aims /Method Results Discussion Conclusion
Results:
74 wardround entries reviewed
• 9 weekend entries
• 7 outliers
57
3
12
2
lower limb
polytrauma
spine
upper limb
P.T.O…
Wardround details
Name of consultant leading wardround
Entry date
Entry time
Patient identification
96%
97%
86%
66%
% documented
P.T.O…
Clinical details
Active issues
Resus status
Sig PMH
Diagnosis
Admission date
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
34%
1%
5%
18%
0%
% documented
P.T.O…
Management and investigations
Radiology report
lab results
Management undertaken
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
5%
9%
24%
% documented
P.T.O…
Clinical assessment
Clinical impression
Discussion with patient
Observations
Examination findings
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
34%
35%
62%
38%
% documented
48%38%
14%
obs stable apyrexia (n=36)not documented (n=28)actual obs reading (n=10)
P.T.O…
Management plan
Dicharge plans
weightbearing status*
Ongoing managment plan
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
19%
14%
92%
% documented
P.T.O…
Documenting doctor
contact bleep
grade
signature
name of doctor
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
70%
45%
82%
54%
% documented
Wardround details
Clinical details
Management and investigations
Clinical assessment
Management plan
Documenting doctor
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
On average
Section 1: Background
BackgroundBackground
Section 4: Discussion
Aims /Method Results Discussion Conclusion
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???
We should not just look at the figures, but focus on why good documentation is really important for ours patients and staff.
Who are the stake holders?
Example scenario:
What is in the literature?
checklists / proforma Electronic wardrounds
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
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
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
Electronic wardrounds
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
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
Electronic wardrounds
ELECTRONIC WARDROUNDS!? Sounds like a distant future for us at BUSH…
Electronic wardround:
Pragmatic solutions:
1. Education 2. Improve ease of patient note access and navigation3. MDT wardrounds 4. Wardround “checkers”5. Be conscientious of the limits of juniors (a human being)6. Proformas 7. Electronic wardround
BackgroundBackground
Section 5: Conclusion
Aims /Method Results Discussion Conclusion
• 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:
Action plan
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