Initiative to improve quality of paediatric ward-round documentation by application of ‘SOAP’ format

Problem

Audits on record-keeping practices at our multidisciplinary hospital revealed that ward-round notes (handwritten clinical notes by the doctor during ward round) were unstructured and carried limited as well as dissimilar information chosen differently by different doctors. While there was satisfactory compliance with regularity, legibility, timing, drug prescriptions, investigation records and vital monitoring, there was marked inconsistency in the reporting of clinical information between doctors. This risked omission of vital facts such as developments during hospital stay, impression of progress, revision in clinical diagnosis, justification for change in medicines or advice for a new test. The paediatric team realized that this inconsistent and incomplete documentation lead to lack of clarity in communication between paediatricians which in turn could compromise patient safety and medico-legal integrity. To address these concerns the department decided to focus on improving their documentation (online supplemental figure 1, fishbone diagram).

Available knowledge

Well-written case notes provide accountability, corroborate the delivery of appropriate services, support clinical decisions,1 2 promote effective communication and prevent patient harm.3 Inadequate communication between different health professionals is associated with discontinuity of care, which can lead to errors and compromise patient safety.4 In present times, clinical notes also serve as a valuable document to audit the quality of healthcare services offered,5 determine issuance of insurance claims and, importantly, serve as a documentary evidence for medicolegal purpose.6

Despite its importance, clinical record keeping is often given a low priority, and it is common to find missing information and inconsistency between the entries.5 Often, there is great variability in the format of clinical notes among different healthcare professionals and hospitals in different countries.5 These may be influenced by the doctor’s/healthcare professional’s years of experience, previous incidents (i.e. lessons that have been learnt) and relevant circumstances of the case (acute deterioration of the patient, etc).5 In densely populated nations such as ours, an additional role is played by limited consult times from enormous caseloads, resulting in priority towards clinical interaction over documentation.7

The onus for improving records lies with individual health professionals. Structuring the clinical records especially at the time of admission is known to improve the quality of information recorded.8–10 This reduces clinical errors and improves patient outcomes.8 In the same context, ward-round proforma or templates have been employed to standardise recording of patient progress. This has demonstrated an improvement in documentation practices,11–13 patient safety,4 12 14 15 efficiency in ward rounds16 as well as completeness of records.17 These proformas have been typically designed to capture comprehensive information pertaining to a particular specialty (eg, surgery or orthopaedics4 12 13 15–17) or a disease (eg, deep venous thromboembolism).14

Another method commonly applied to improve documentation practices has been audit exercises to sensitise doctors regarding their performance. This includes educating them via trainings or reminder communications to perform against a benchmark. These audits engage either a concerned specialty centric template (eg, Shark, Crabel, Star, to name a few)18–20 or adhere to norms defined by quality accreditation programmes.21 22

Both proforma as well as audit templates have focused on comprehensive aspects of record keeping such as investigations, drug prescription, information to patients, date and time of records, and regularity besides characteristics of the clinical information. There appears to be a paucity of literature demonstrating methods focused only on the nature of the clinical information relayed in the note.

Rationale

Recognising our need to structure our notes, we explored the methodology used by Dolan et al,4 i.e. structuring of the records incorporating the subjective, objective, assessment and planning (SOAP) template. The SOAP acronym is a derivative of problem-oriented medical record practice, which warrants that clinical records be structured around the patient’s problems and updated in detail on a daily basis.22 SOAP prototype provides the cognitive framework for clinical reasoning while serving as a reminder for specific aspects of clinical information.3 A progress note under this format reflected essential parameters of ongoing patient progress and treatment information. We inferred from the available literature that structuring our notes will improve information recorded and thereby quality of documentation.

It was felt that SOAP format was suited to our system for two reasons. First, it served our requirement to balance out the neglected clinical parameters and save us from the implementation of exhaustive notes which could prove labour and time intensive for a busy system like ours. Second, its simple design circumvented the need for detailed department specific proforma, which would have required multiple approvals as well as institution-wide reforms around creation of distinct case files for different departments.

Aim

Our Specific, measurable,applicable,realistic and timely (SMART) aim was to improve the quality of documentation in ward-round notes, for paediatric inpatients aged between 1 month and 15 years, by application of the SOAP template to at least 80% of the eligible notes by 6 months. Eligible notes constituted two out of all the ward-round notes written during 24 hours of an inpatient stay.

Context

Sitaram Bhartia Institute of Science and Research is a non-profit, 70-bed hospital providing care across multiple disciplines via its outpatient department (OPD), inpatient department services (IPD) and emergency services. The department of paediatrics caters to an average of 1800 outpatient and around 100 inpatient neonatal and paediatric admissions monthly. Of these inpatients, 70%–80% are healthy newborns admitted in the ward, while the remaining 20%–30% comprise sick children treated either in the ward, the paediatric intensive care unit or the neonatal intensive care unit (NICU). The team has full-time consultants who provide round-the-clock care, following a dedicated roster. Paediatricians undertake two ward rounds in the morning (along with a demanding OPD roster) and two in the night shift for admitted patients. In addition, they also attend emergency cases round the clock. All paediatricians meet together once a day, during morning departmental huddle for the purpose of clinical handover and assigning of departmental responsibilities.

Record keeping for all hospital inpatients is maintained on paper in case files composed of case sheets, labelled for its specific purpose and organised serially in a folder. While sheets filled by doctors at the time of admission have preprinted formats specific to that specialty (online supplemental annexure 1), progress records are entered during ward rounds in blank sheets used throughout the hospital for all specialties (online supplemental annexure 2). We formed a team comprising two paediatricians, a quality executive, a quality consultant and one staff from the medical record department. The quality executive was responsible for the creation of the SOAP template in the patient file. The paediatrician, along with the quality executive, audited ward-round notes under all four headings and noted the compliance towards whether the content filled under these headings was appropriate or not. The medical record team ensured appropriate storage as well as access of patient records to the paediatricians. The quality consultant led brainstorming and feedback sessions with the entire team. Data analysis and implementation of change ideas were undertaken collectively by the quality team and clinicians.

We focused on documentation in paediatric cases that ranged from 1 month to 15 years of age, as they represented the sicker subset of admissions. We assumed that these patients were at most risk from substandard record keeping and hence deserved priority intervention.

Interventions

In May 2019, we met all paediatricians and highlighted the concerns arising from unstructured ward-round notes, particularly the aspect of selective and variable patient information by different doctors compromising team communication and medicolegal integrity. We introduced the concept of structuring these notes using the SOAP format and shared information material on its methodology. The concept was appreciated by all, and many expressed familiarity with it from their training years. Following their agreement to use the format, training sessions were conducted to educate all consultants to implement it during rounds. All consultants were covered using serial training sessions by the end of the month. In the months of May 2019–July 2019, we evaluated our paediatric case files to learn our compliances with SOAP format (this constituted as our baseline). For this, we identified a senior consultant who audited all paediatric case records daily and ascertained whether information relayed in the ward-round notes matched the SOAP format and was relevant to each component of the acronym. However, we observed only a marginal compliance of 13% with SOAP use for these months.

Following this, we organised a brainstorming session where we sought their ideas on how to imbibe the practice in routine functioning. Our front liners put forth several reminder-based solutions which were tested using month-long plan–do–study–act (PDSA) cycles.

Study of the interventions

Every intervention was tested individually, and outcomes were analysed over the corresponding time frame using quantitative data to help ascertain their impact. We noted dismal compliance with SOAP notes with the first two interventions, while the last two demonstrated a significant rise in SOAP application.

We observed no improvement on testing our first intervention (verbal team reminders) even though it was easy and simple to execute. While the team agreed to use the SOAP format after this intervention, they were often using it partially. Paediatricians then recommended that we provide specific component-based reminders, which led to our second intervention. This intervention led to a marginal improvement with some paediatricians finding this a criticism of their documentation efforts. We therefore discarded the first two interventions. Our third intervention (visual reminder in case sheets) led to a steeper rise in compliance from 19% to 52% in the month of October 2019. This improved further to 60% in November 2019. This change was appreciated by the team as it was a strong cue to use the format especially during busy shifts. Our maximum compliance reached 92% against a low case load and stayed close to 90% even during heavy caseloads.

Both our outcome and process measures plunged with the arrival of COVID-19. Further, ability to enter the acronym also suffered and implementation processes declined from 67% to 33%, resulting from reduced manpower and COVID-19 driven anxieties. This warranted a switch to our fourth intervention in August 2020, which demonstrated a rise in SOAP use from 72% to 91% in December 2020.

Measures

We calculated the notes expected to be filled under SOAP format during the 24 hours of a patient’s stay and identified them as eligible notes. One note, each from the day and the night shift, that is, two out of four notes constituted eligible notes.

We studied ward-round notes wherein ‘all’ four headings of the SOAP template were used. Our consultant also studied whether information conveyed against each heading was appropriate and relevant to it. Our outcome measure was the percentage of notes written in SOAP format. Our primary process measure was compliance with the acronym on ward-round case sheets. We also monitored our compliance to our subsequent change idea in which we used visual prompters on the department information board. Our balancing measures were paediatrician and patient feedback during the implementation of the SOAP acronym.

Analysis

The outcome of the project was analysed using standard run charts which identified statistical significance in the outcome measure assessed on a regular basis. Based on run-chart rules proposed by Anhøj and Olesen, we saw a shift in the run on one side of the median, so we revised and calculated a new median.23 Also, towards the end of every cycle we collected team feedback using group discussions, focusing on the ‘specific’ intervention to learn team experiences and sentiments.

Summary

A pertinent and a succinct ward-round note is a critical link to safe care delivery. Our ward-round notes were mostly unstructured and unmethodical, compromising interprofessional communication, patient and medico-legal safety.

We selected the SOAP format noting its attribute to capture specific information while offering flexibility to the doctor relying on a simple format. Team exchanges were instrumental in learning methods to apply the concept. Use of visual reminders in the form of acronyms emerged successful in embedding the change. Special cause variation from unexpected pandemic environments had a dense impact, warranting shift in the change idea, right in the middle of the journey. Regular physician engagements and reciprocity towards their sentiments aided continued team participation especially during unforeseen disruptions.

Interpretations

Out of the four interventions tested, visual reinforcements, i.e. SOAP acronym on the case sheet and visual reminder during huddles, had stronger and sustained impact. Visual reminders proved effective even during higher caseloads. This corroborates with previously tested interventions such as prefilled templates, which demonstrate sustained impact.4 12–17

Themes from team feedback revealed that structured notes translated into meaningful clinical practice. Improved reflection of plan in the notes facilitated efficient discharge preparations besides enhanced communication opportunities with the family. Systematic representation of patient assessment also facilitated early detection in clinical deterioration and timely escalation of treatment. Meaningful practice perceived with structured notes proved to be a valuable factor in maintaining gains for 5 months in the pre-COVID phase. Subsequently, a minor modification of using reminders in department information board resulted in a prompt revival after the initial COVID-19 phase. This confirmed our belief that the clinicians valued the change.

However, despite the internal motivation, 100% application was difficult to achieve, likely due to prevailing time constraints of care aspects in a country with high caseloads.

Lessons and limitations

We learnt that front-line participation depended not just on the strength of the idea but also on team engagement during the execution phase. Selection of an idea suited to local environments is important. Selection of a methodology that circumvented the need for proforma approvals for a singular department and supported easy replication across other departments was pertinent for our set-up. Further, mindful of our manual record-keeping practices on paper, we found that selection of a template which was succinct and not labour intensive and which respected time constraints proved useful. We also observed that working with a team of full-time employed consultants with aligned departmental goals contributed to their increased participation on a regular basis even during the pandemic.

Our limitation remained that while we achieved uniformity in record keeping by filling under four headings, we could not confirm whether this information was complete, corroborating to the exact clinical situation and of most relevance. We assumed that the content which doctors were mentioning under these headings was thorough and accurate. Furthermore, sustainability of our modified intervention during higher paediatric inpatients is still to be observed.

Way forward

Going forward, we will be continuing with acronym display in case sheets and with the weekly visual reminders during huddles when the COVID-19 phase comes to an end. We also intend to expand the scope of the format application to neonatal admissions. Seeing our success, two other departments, that is, medicine and obstetrics and gynaecology units, have taken up this improvement project.