Introduction With increased emphasis on consultant led care and the frequency of ward rounds, documentation is paramount. We observed that during busy periods, the progress and plan from the evening consultant led ward round was not always transcribed to medical notes.
Method We devised an efficient, clear and practical way of documenting the patient’s progress and plan made during these consultant led rounds – whether it be a ‘board round’ or bedside review. We designed and printed a proforma onto adhesive stickers which can be completed by the ward patient board list or bedside and then transferred to the medical notes. The proforma allows for notes on progress through the day and plan.
Since implementation, we have carried out an audit to evaluate whether the stickers improved:
Documentation of the evening ward rounds
Adherence to the medical plan
Communication of the medical plan through the multi-disciplinary team (MDT)
We compared five days of notes of acute medical admissions (31 notes) with a sample of notes from previous admissions (31 notes).
Results Since the introduction of stickers, 100% of patients audited had an evening ward round entry with a plan documented. This compared to only 16% prior to the introduction. Since our intervention, we noted that the plan documented was adhered to in 94% of patients compared to 80% previously. On surveying the nursing staff, we found 80% of nurses agreed the stickers improve communication of the medical plan and 100% agreed they made it easier for the night team to follow the plan made.
Conclusion Bedside reviews or board based ward rounds will always generate a plan, and it is essential this plan is accessible and recorded in the correct place. The stickers allow for an efficient and rapid way for the reviews and decisions made to be recorded in the medical notes; contributing to continuity of care. The evening round stickers also improved communication through the MDT hence improving adherence to the plan. We recommend any department looking to improve documentation, consider alternative and inventive methods which can contribute to efficiency and improve patient care.
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