1018 Implementing A Standardised Orthopaedic Admission Pro-Forma to Improve Adherence to The Royal College of Surgeons of England (RCSEng) Best Practice Clerking Guidelines

Abstract Introduction Within our Trust, Orthopaedic patients are clerked in on A&E notes via freehand text. Audit, clinical incidents, and root cause analysis revealed suboptimal documentation. Using RCSEng Best Practice Guidelines we designed, implemented, evaluated the impact of an admission pro-forma quality clerking. Method An clerking was designed based standards set by feedback from colleagues. First- second-cycle data collection involving quantitative against domains conducted before (n = 23) after 25) intervention. Fisher’s exact test performed to calculate statistical significance data. A qualitative survey gain pro-forma. Results Observations, allergies, smoking history were omitted over half documentations. Medical/surgical management plans well documented regardless. Intervention resulted statistically significant increases 7 out 12 domains, most notably allergies (p < 0.00001). Qualitative positive; 100% those surveyed stated that ‘improved clerking‘ ‘benefited decision making’. Conclusions Our study demonstrated implementing improved adherence best practice guidelines compared documentation standardised process improving level