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Abstract
Background Admission notes are an important aspect of clinical practice and a vital means of communication among healthcare professionals. Incomplete or poor clinical documentation on admission can lead to delayed surgery.
Patients and methods A retrospective analysis of 20 consecutive admission notes to our department was compared against the Royal College of Surgeons standards (GSP 2014). A new admission proforma was designed, and after the introductory period, two further retrospective cycles were performed.
Results In total, 60 admission notes were analysed. Following the introduction of the proforma, there was an overall improvement in the documentation of the quality and quantity of notes studied.
Conclusion Our study demonstrated that a well-structured admission protocol can improve the overall quality of admission notes.
- Quality improvement
- Clinical Audit
- Quality measurement
Data availability statement
Data are available upon request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Existing evidence highlights the importance of accurate and comprehensive admission notes. It is recognised that using structured admission forms could improve the quality of clinical documentation, thereby enhancing patient care.
WHAT THIS STUDY ADDS
This quality improvement project led to the development of a new orthopaedic admission proforma. It demonstrates the effectiveness of a standardised proforma in improving the quality of admission notes.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study suggests that adopting structured admission proformas can enhance documentation practices in orthopaedic settings. It also underscores the need for different departments to implement a structured documentation protocol to improve the quality and efficiency of patient management.
Problem
The admission documentation for orthopaedic patients in a busy regional trauma service merely consisted of an admission note, written by the admitting doctor, using their preferred method of documentation. Consequently, during the handover of patient care to acute admissions with various clinical teams, it was noted that the quality of admission documentation varied considerably. Moreover, incomplete, and poor-quality admission notes result in increasing incidences of delayed surgery. As such, a need for quality improvement and a degree of standardisation was expressed. Therefore, we aimed to audit the design and practice of the current admission documentation, introduce a new orthopaedic admission proforma and measure its impact within our department.
Background
Documentation in healthcare is vital to ensure safe and satisfactory patient management. All notes should be accessible and comprehensive to healthcare professionals. Complete documentation containing all required aspects will guarantee good communication between healthcare professionals. This will enhance the standard of treatment for each patient and lower the incidence of error.1 There is existing evidence showing that structured proformas for clinical record keeping improve overall management, efficacy and efficiency of the healthcare system.2 Moreover, it is shown that a structured ready-made proforma is desired for surgical admissions.3 Accurate and complete notes decrease the chances of medicolegal consequences in response to clinical errors.4 Existing studies indicate that admission notes are usually incomplete owing to a lack of knowledge and standards awareness.5 As such, the Royal College of Surgeons in England (RCSEng) has published guidelines for record keeping.6
Baseline measurement
This was a retrospective study. A total of 20 consecutive admission notes submitted to our department were compared against the RCSEng standards6 in April 2020. All the 20 admission notes were hand-written. Microsoft Excel, 2019 was used for data collection. Again, data were compared against RCSEng standards6 including patient identification, author name, date, diagnosis, history of presenting illness, medical history, regular medications, allergies, social history, functional status, systemic review, examination findings, investigation results and management plans. The aim was to ensure a proper and thorough handover of patients, especially as inpatient follow-up is not necessarily performed by the admitting team. We agreed to an acceptable margin of 80% or more for all aspects of the admission note. In the initial cycle, documentation was poor for 50% of the aspects including author name (50%), date (70%), medications (20%), functional status and investigation results (30%), social history (40%), and systemic review (75%). However, the remaining aspects had a satisfactory documentation level exceeding 80%. These remaining aspects included the patient name, diagnosis, medical history, allergies, examination findings and management plan. We planned to continue using the same Excel sheet as a data collection tool to measure the quality of admission notes in upcoming cycles.
Design
In our audit, incomplete documentation was noted. As the default admission note was written freehand, it was possible to omit important aspects of the admission note. A quality improvement (QI) team, consisting of a consultant, registrar and senior house officer was established. A proforma template was subsequently designed, aiming to improve the accuracy, efficiency and quality of the admission note. The proforma was designed in line with the standards stated by RCSEng (figure 1). We anticipated that the availability of the proforma on different hospital grounds may be an issue. Therefore, we distributed the proforma to the emergency department and orthopaedic wards. Two plan-do-study-act cycles were completed over 6 months (figure 2).
Designed orthopaedic admission proforma. NH, nursing home; BP, blood pressure; HR, heart rate; RR, respiratory rate; T, tempreture; SO2, oxxygen saturation; CVS, cardiovascular; WBC, white cell count; Hb, haemoglobin; CRP, C reactive protein; INR, international normalised ratio; ESR, erythrocyte sedimentation rate; CXR, chest xray; GCS, glascow coma scale; AMTS, abbreviated mental test score; FIC, fascia iliaca block.
PDSA cycles. PDSA, plan-do-study-act.
Strategy
PDSA 1
For the initial intervention, an admission proforma was designed and introduced along with the baseline measurement results at the morbidity and mortality meeting. The proposed proforma (figure 1) was discussed with all attending consultants, doctors and trauma coordinators. The authors agreed to use the proforma for all orthopaedic admissions. This resulted in an overall improvement in the quality of admission notes. However, concerns about proforma availability were raised by junior staff, as it was difficult to locate the proforma within a busy emergency environment. In addition, some staff members reported the need for larger or smaller spaces to detail notes in the proforma.
PDSA 2
Drawing on the feedback received from the staff. As a solution to proforma availability, we created a specific slot in different departments for the admission proformas to be placed, and staff were made aware of their location. In addition, the proforma was made available to print from any computer in the hospital. This made the proforma very easily accessible but was also advantageous as this allowed editing of the proforma format when required. This was well accepted by the staff, and further improved the quality of the admission notes.
Results
In total, 60 admission notes were analysed. The least well-recorded data were author name (50%), social history (40%) and functional status (30%). These improved to 100%, 70% and 65%, respectively, after the introduction of a standardised proforma. Other records also improved, apart from patient ID (90%), examination findings (100%) and management plans (100%), which remained unchanged (table 1).
Data collected over the three cycles
The most striking improvement was observed in medication documentation, increasing from 20% to 95%. Investigation results only improved by 5%, though this was likely due to results not usually being available until the patient is admitted to the ward.
Lessons and limitations
The strongest aspect of this project was a continuous discussion with the staff following each cycle. This enabled staff to raise their individual concerns about the proforma. As such, appropriate solutions were found and applied, with a productive review of all concerns. However, the unavailability of patient investigation results during the admission process may have caused an artificial lack of improvement in documentation. While some aspects can still be improved, further cycling would be beneficial.
Conclusion
The introduction of the designed orthopaedic admission note proforma resulted in a marked improvement in the quality of documentation. A comprehensively documented admission note is key to effective and safe inpatient management. Moreover, an overall improvement in the quality of admission documentation was identified in our institution following the introduction of a standardised proforma.
Data availability statement
Data are available upon request.
Ethics statements
Patient consent for publication
Footnotes
Contributors MZ is acting as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.