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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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Detalles Bibliográficos
Autores principales: Armstrong, Edward J, Carpenter, Kilda J
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Cureus 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9701495/
https://www.ncbi.nlm.nih.gov/pubmed/36447809
http://dx.doi.org/10.7759/cureus.31931
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author Armstrong, Edward J
Carpenter, Kilda J
author_facet Armstrong, Edward J
Carpenter, Kilda J
author_sort Armstrong, Edward J
collection PubMed
description 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.
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spelling pubmed-97014952022-11-28 A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit Armstrong, Edward J Carpenter, Kilda J Cureus Quality Improvement 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. Cureus 2022-11-27 /pmc/articles/PMC9701495/ /pubmed/36447809 http://dx.doi.org/10.7759/cureus.31931 Text en Copyright © 2022, Armstrong et al. https://creativecommons.org/licenses/by/3.0/This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Quality Improvement
Armstrong, Edward J
Carpenter, Kilda J
A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit
title A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit
title_full A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit
title_fullStr A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit
title_full_unstemmed A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit
title_short A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit
title_sort standardized ward round proforma improves documentation in a specialist stroke unit
topic Quality Improvement
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9701495/
https://www.ncbi.nlm.nih.gov/pubmed/36447809
http://dx.doi.org/10.7759/cureus.31931
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