Key result
Implementation of a sticker pro-forma (STAR) for daily ward rounds improved documentation completion rates from 47% at baseline to 88% in the third audit cycle.
Why the study?
The study was conducted to audit ward round documentation quality in a Plastic Surgery department using the SAFE Ward Round Tool and create an in-house pro-forma.
Does the introduction of a sticker pro-forma improve the completion rate of daily ward round documentation in a Plastic Surgery unit?
Does the introduction of a sticker pro-forma improve the completion rate of daily ward round documentation in a Plastic Surgery unit?
The introduction of a structured sticker pro-forma significantly improved the completeness of daily ward round documentation in a plastic surgery unit.
Answers are grounded in this paper and cite their sources.
May support pro-forma use for ward documentation in surgery; leaves open generalizability and durability.
Aim Our goal was to audit the quality of the ward round documentation in our Plastic Surgery department by using the SAFE Ward Round Tool of the RCS Edinburgh’s as a reference standard, and to create an in-house pro-forma based on results and discussion. Method An initial cycle based on the SAFE Tool was undertaken with prospective audit of individual daily ward round entries. A sticker pro forma was introduced and re-audit was done using the same criteria. Based on results and discussion, the pro-forma was further improved. Re-audit was performed to assess percentage of completion of its contents. Results The first cycle showed 47% (n = 42) completion rate and re-audit after implementation of the sticker found a rise up to 70% (n = 42). The third cycle examining solely sticker completion yielded a compliance of 88% (n = 61). This improvement reflected to the enthusiastic comments received from staff working in allied specialties. Conclusions Significant lapses in daily ward round documentation were revealed by our methodology. A sticker pro-forma, which we have named the Surgical Tool for the Assessment of Rounds (STAR), was introduced and provided measurable and sustainable improvements on our daily ward round practice. That had as a result the safeguarding of patient safety in the frame of Good Medical Practice. We suggest same methodology to be followed based on the SAFE Ward Round Tool for surgical ward rounds improvement in all the surgical and interventional specialties particularly when there is a component of emergency admission in their daily practice
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Koumoullis et al. (2020) studied Ward round documentation (n=145). Sticker pro-forma (STAR) vs. Standard practice (initial cycle) was evaluated on Completion rate of ward round documentation. Implementation of a sticker pro-forma (STAR) for daily ward rounds improved documentation completion rates from 47% at baseline to 88% in the third audit cycle.
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