A quality improvement project using a problem based post take ward round proforma based on the SOAP acronym to improve documentation in acute surgical receiving

Dolan, R. and Broadbent, P. (2016) A quality improvement project using a problem based post take ward round proforma based on the SOAP acronym to improve documentation in acute surgical receiving. Annals of Medicine and Surgery, 5, pp. 45-48. (doi: 10.1016/j.amsu.2015.11.011) (PMID:26858834) (PMCID:PMC4706565)

Abstract

Objectives: Ward round documentation provides one of the most important means of communication between healthcare professionals. We aimed to establish if the use of a problem based standardised proforma can improve documentation in acute surgical receiving. Methods: Gold standards were established using the RCSE record keeping guidelines. We audited documentation for seven days using the following headings: patient name/identification number, subjective findings, objective findings, clinical impression/diagnosis, plan, diet status, discharge decision, discharge planning, signature, and grade. After the initial audit cycle, a ward round proforma was introduced using the above headings and re-audited over a seven day period. Results: The pre-intervention arm contained 50 patients and the post intervention arm contained 47. The following headings showed an improvement in documentation compliance to 100%: patient name/identification number vs 96%, subjective findings vs 84%, objective findings vs 48%, plan vs 98%, signature vs 96%, and grade vs 62%. Documentation of the clinical impression/diagnosis improved to 98% vs 30%, diet status rose to 83% vs 16%, discharge decision to 66% vs 16%, and discharge planning to 40% vs 20%. Conclusions: Standardised proformas improve the documentation of post-take ward round notes. This helps to clarify the onward management plan for all aspects of a patient's care and will help avoid adverse events and litigation. This should improve the quality and safety of Patient Care.

• Item Type: Articles
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Dolan, Dr Ross
• Authors: Dolan, R., and Broadbent, P.
• College/School: College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing
• Journal Name: Annals of Medicine and Surgery
• Publisher: Elsevier
• ISSN: 2049-0801
• ISSN (Online): 2049-0801
• Published Online: 12 December 2015
• Copyright Holders: Copyright © 2016 The Authors
• First Published: First published in Annals of Medicine and Surgery 5:45-48
• Publisher Policy: Reproduced under a Creative Commons License