741 Introducing a Ward Round Proforma to Improve Surgical Ward Documentation

Abstract Aim To improve surgical ward round documentation in a local general surgery department through a standardised ward round proforma. The General Medical Council and Royal College of Surgeons have published guidance on the importance of accurate ward round documentation and this intervention intends to improve adherence to guidelines. Method A prospective study was carried out reviewing ward round documentation within the upper gastrointestinal surgery department at St Peter’s Hospital, Chertsey, in accordance with GMC guidance. 100 consecutive wards round entries were reviewed according to 16 parameters. An online proforma was implemented on Oracle Cerner and presented to the team after results of the audit. The proforma will be introduced for one month where a repeat review will be conducted to determine adherence to ward round documentation guidelines. Results The first audit cycle found strong adherence to guidelines with entry time (99%), ward round plan (98%), clinical diagnosis (94%), and current issues (94%). Areas for improvement included examination findings (82%), signature (69%), documentation of the patients’ observations (65%), consultant in charge of patients’ care (19%), and contact number (3%). Implementation of a ward round proforma aims to both save clinicians’ time with auto-populated patient details and improve adherence with ward round documentation across the department. Conclusions The project has shown areas for improvement within our department’s ward round documentation. A proforma reflecting these areas has been designed and implemented in our trust with follow-up review planned shortly to review whether sustainable improvement has been achieved.