Improving documentation within the acute stroke unit: Introducing a stroke specific clerking proforma

The Royal College of Physicians outline the guidelines for acute stroke management, they highlight the importance of early identification to enable prompt and effective treatment. The first contact that a clinician has with a patient is usually at the point of clerking. The information obtained and impression formed are the key factors which determine the management plan. The documentation of the information gleaned is subsequently used by all of the medical team to determine the sequence of events from admission. It is crucial in determining any progression of symptoms, of particular importance in this group of patients in whom this can signify potentially fatal consequences. The quality of clerkings of patients admitted to the acute stroke unit in the Royal Devon and Exeter hospital was analysed and subjective data was obtained from the junior doctors involved in this process to determine how well these were being completed. Baseline measurements showed that junior doctors lacked confidence in this process and the initial audit demonstrated that only half of the recommended categories were being completed. To address this issue a stroke specific admission proforma was made and piloted on the ward. Following this, a re-audit was completed which showed a significant improvement in the quality of clerkings produced.