Do medical admission pro formas ­improve the completeness of documentation? A multisite observational study

Abstract

There is little evidence as to whether clerking pro formas are more or less effective than continuation sheets for the acute medical admission clerking process. This two site audit aimed to assess the effect of introducing clerking pro formas on the completeness of documentation in 32 areas. Data were collected at two sites both pre-and post-introduction of two different clerking pro formas, and a two-tailed z-test used to assess the signifi cance in changes in documentation at each individual site and combined across both sites. Site one showed improvements in 23/32 areas, with 7/32 (21.9%) being signifi cant; three areas saw a decline and 1/32 showed a statistically signifi cant decline. Site two showed improvement across 25/32 sites with 19 (59.4%) being signifi cant; there were no areas showing less complete documentation. Cross-site analysis showed improvements in 30/32 categories, with 15 (46.9%) being signifi cant; one area showed a non-signifi cant decline. The greatest percentage improvement was seen in documentation of cardiopulmonary resuscitation / escalation decisions-an important consideration in this clinically unstable population. The introduction of clerking pro formas across two sites improved the completeness of documentation in a number of areas. This data supports the widespread introduction of clerking pro formas as a tool to improve the completeness of admission documentation.