159 The Role of Proformas in Improving the Documentation of Surgical Ward Rounds

Abstract Introduction Several NHS trusts rely on handwritten notes, including ward round (WR) reviews. These are essential in-patient care and must be completed/documented thoroughly. The General Medical Council Royal College of Surgeons have both published guidance WR documentation. Method This was a prospective study aiming to review documentation within general surgery at Frimley Park Hospital. 17 entries were reviewed using an 18-point checklist. A proforma created based gaps in introduced for two months before repeat conducted. third conducted after additional month monitor sustained improvement. Results Strengths the baseline included leads (100%) plans (100%), legible handwriting (95%), NEWS score (88%). Common weaknesses full observations, anticoagulation (both 6%), relevant bloods imaging 12%). post-proforma found improvement all 18 areas documentation, with five elements scoring 100%. Documentation improved from 6% 94%, 12% 82%, observations 76%. Higher WRs linked pre-prepared proformas, lower scores post-take WRs. repeated month, showing consistently results areas. Conclusions project has shown significant sustainable proforma. would therefore recommend continued use proforma, junior doctor change over show sustainability.