6081 Introduction of a ward round proforma on a general children’s ward with an aim to standardise documentation

Objectives Ward rounds are key components of inpatient care, allowing for coordination, planning and communication, which is vital for effective and efficient care.2 5 Despite this, considerable improvements are required to make them safe and effective as there still appears to be a lack of standardisation in current practice.4 6 It is well known that poor documentation can lead to breakdowns in continuity of care and communication amongst teams with subsequent impact upon quality of care and safety.3 The use of proformas and checklists have shown to improve patient outcomes, patient flow and the quality of documentation.1 A local audit demonstrated that ward round documentation was poor, leading to the proposal of implementing a proforma to improve and standardise documentation practice. Methods As part of a more general Quality Improvement Project to improve clinical documentation in our general paediatric unit in the West Midlands we have introduced a standardised proforma for inpatient medical ward round review. The proforma was introduced in August 2023. The proforma was internally peer-reviewed before approval by departmental governance and the Trust health documentation groups. A pre-audit was carried out to analyse the current clinical practice in regards to documentation and 32 inpatient clinical notes were reviewed. A post-audit on 32 inpatient clinical notes was then done to analyse if the introduction of the proforma enhanced clinical documentation. The proforma was trialled for one month before collecting the post-audit data. Results a pre- and post-audit proforma included twenty-two questions (see attached tables). The introduction of the ward round proforma allowed a marked improvement on the documentation on eleven domains: Consultant name (75% vs 93%), Junior clinician name/signature (84% vs 100%), Stamp with GMC/NMC details of junior clinician (59% vs 87%), background of patient (59% vs 87%), two patient identifiers on page (81.25% vs 87%), PEWS score (65.6% vs 83%), investigations results (75% vs 90%), Current medications (62% vs 81%), physical examination (90.6% vs 100%), Impression after consultation/revision of diagnosis (18.75% vs 78%) and fluid balance (37% vs 75%). Documentation of date and working diagnosis remain 100%. Conclusion The overarching aim of the project was to improve ward round documentation. The use of a standardised proforma demonstrated significant improvements and therefore, it will be fully adopted as part of daily practice in a children's ward based in the West Midlands. References Armstrong E, Carpenter K. A standardized ward round proforma improves documentation in a specialist stroke unit 2022. Dean J. Ward rounds fit for the future, good practice for multidisciplinary inpatient review 2019. Peate I. The Ward Round 2021. Powell N, Bruce C, Redfern O. Teaching A 'good' ward round 2015. Modern Ward rounds good practice for multidisciplinary inpatient review. Royal College of Physicians 2021. Waters L, et al. Ward round accreditation: an innovative quality improvement project to develop and improve the existing medical ward round at Warrington Hospital 2019.