972 Improving Surgical Ward Round Documentation: A Closed-Loop Audit

Abstract Background The surgical ward round (WR) is a critical multidisciplinary process. Adequate documentation of WRs have medicolegal and patient safety implications. Checklists have been known to improve outcomes, but there is no set template recommended for WR documentation. Aim This quality improvement project aimed to firstly, identify areas of poor documentation in WR notes and secondly, to improve these areas with the use of a template. Method Over three months, 20 dates were randomly chosen with an online random data generator. Variables were identified from literature recommendations. WR notes from 54 patients were analysed (cycle 1). Results were discussed in an expert-led meeting, and templates were constructed. To assess any improvement, 20 prospective WR notes were similarly analysed (cycle 2). Results Templates significantly improved documentation of lab findings (p=0.02), investigations (p=0.02) and plan (p=0.01). For all other variables, no significant change was found. Fluid balance and drug chart reviews were significantly worse after the template introduction. Fluid balance, Estimate Discharge Date (EDD) and nursing presence on the round scored particularly poorly in both cycles. Conclusions The use of a WR template improves some aspects of documentation. Further work and perhaps a more robust intervention is required to improve overall WR documentation.