Improving Clinical Workflows: A Quality Improvement Project on Admission Documentation Standardization

Introduction Complete admission notes are critical for patient safety and care continuity. A baseline audit of 40 surgical admission records at our tertiary hospital found major omissions: only 60% documented History of Presenting Illness (HOPI), 20% recorded Past Medical History (PMH), 60% captured Examination findings, and 47.5% included a Visual Aid. We implemented a standardized admission proforma to improve documentation completeness. Methods In April-May 2025, we conducted two Plan-Do-Study-Act (P.D.S.A.) cycles. Baseline data were collected by chart review of 40 consecutive admission notes. Cycle 1 introduced a first-version proforma; notes were reaudited (n = 40). Cycle 2 refined the form based on user feedback; a second reaudit was performed (n = 40). Key fields - HOPI, PMH, Examination, and Visual Aid - were scored as present or absent. Results After Cycle 1, HOPI rose to 100%, Examination to 97.5%, PMH to 30%, and Visual Aid fell to 27.5%. Following Cycle 2, HOPI and Examination reached 100%, PMH improved to 85% (p<0.001 vs baseline), and Visual Aid rose to 75% (p=0.022 vs baseline). Investigations and Management Plan were already at 100% throughout. Conclusions Iterative introduction of a structured admission proforma significantly enhanced documentation completeness. By Cycle 2, all targeted domains except Visual Aid met or exceeded 85% completeness. Standardized templates can reliably improve surgical admission notes and should be adopted broadly.