Improvement in clinical recording keeping following the introduction of an admission clerking proforma for acute general surgical patients

Abstract

Aim: Accurate record keeping, safe handover and optimising management of acute surgical patients has reached a consensus with the publication of the Handover Guidance and theEmergency Surgery Standards by theRCSEng. This novel audit assesses the improvement in accuracy and consistency of clerking following implementation of a proforma for acute surgical admissions. Methodology: Surgical admission clerking notes of 100 patients presenting acutely to a district general hospital were audited against standards of excellence derived from the Royal College of Surgeons Handover Guidance, Emergency Surgery Standards and the Royal College of Physicians Record Keeping Standards. A proforma was constructed and implemented across the unit. A further 100 patient notes were re-audited to assess the effect of the clerking booklet on improving documentation. Results: The proforma significantly improved documentation (p<0.05). Completion of venous thromboembolism risk assessment increased by 62% (p<0.001). Time taken until senior review of the patient post-admission, which occurred in an average of 5.23 hours, improved by 2.53 hours. Conclusion: Implementing an admission surgical proforma significantly improved documentation and standardised the information recorded for patients admitted in the acute setting improving patient safety. It can be used as a future tool to allowunits to audit their delivery of care against the national standards.