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Abstract Aim It has been widely shown that admissions proformas improve the quality of documentation, which is important not only for patient safety but funding secondary to coding within the NHS. The admissions proforma in this busy Tertiary centre was 16 pages long, and frequently not filled out. Therefore, we investigated just how underutilised it was with a view to restructure it, in line with RCSEng Guidance. Method Study completed during November and December 2022. 31 proformas identified, and data collated within 46 possible sections over the 16-page document. Analysed using Excel. The document was then changed, using verbal feedback from spinal fellows, junior doctors, and nursing staff. Results Average completion rate of 41% over all sections. Admission date and time completed in 15% and 36% respectively. Past medical history completed in almost 90% of patients. Allergies and drug history completed 90% and 100% respectively. Physical examination was recorded in 66% of patients. Imaging and ECGs reviewed in 6% of patients. Registrar reviews were documented in 12% of cases and Consultants on 2%. Conclusions There is a clear lack of documentation using the current proforma, and instead senior reviews are recorded on continuation sheets. This leads to difficulty in continuation of patient care, reduced communication and increased time spent on discharge summaries. The new 8-page document will allow clearer documentation, with tick boxes and checklists incorporated to allow easy use for even for doctors providing temporary cover on the spinal unit and will provide a more environmentally sustainable solution.
Marei et al. (Mon,) studied this question.