A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit

Background and aim Ward-round documentation is important for clinical communication and patient safety. Standardized checklists have improved ward-round documentation in surgical and medical settings. This quality improvement project aimed to introduce a standardized ward round proforma to improve d...

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Veröffentlicht in:Curēus (Palo Alto, CA) CA), 2022-11, Vol.14 (11), p.e31931
Hauptverfasser: Armstrong, Edward J, Carpenter, Kilda J
Format: Artikel
Sprache:eng
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Zusammenfassung:Background and aim Ward-round documentation is important for clinical communication and patient safety. Standardized checklists have improved ward-round documentation in surgical and medical settings. This quality improvement project aimed to introduce a standardized ward round proforma to improve documentation in a UK specialist stroke unit. Methods Ward round entries were assessed against internally agreed standardized criteria. A stroke-specific ward round proforma was designed and introduced with input from the multidisciplinary team. A repeat audit was performed, including assessment of the use of different proforma sections. Multidisciplinary team members were invited to provide feedback via an anonymous online survey. Results A total of 111 ward round entries were reviewed before the proforma was introduced. Ninety-five ward round entries were reviewed following introduction of the proforma, and 84.2% of these used the proforma for documentation. Overall documentation of standardized criteria improved from 48.7% to 62.1% with substantial improvement seen in documentation of neurological examination, presence/absence of mechanical venous thromboembolism prophylaxis, and blood test results. Multidisciplinary team feedback was positive. Conclusions The stroke-specific ward round proforma improved the quality and consistency of documentation in the unit. An updated proforma was designed using these results and multidisciplinary team feedback.
ISSN:2168-8184
2168-8184
DOI:10.7759/cureus.31931