347 General Surgery Ward Round Documentation: A Quality Improvement Project

Abstract Aim To improve the rate of inclusion, and quality, important clinical details in ward round documentation General Surgery inpatients at a district general hospital. Method A 15-point checklist was created, containing which were considered appropriate to be included all wards entries. An initial audit 71 entries performed, assessing their compliance this checklist. Following this, proforma created put into use. One month later, 106 sampled for repeat audit, 85 them having used (80.2% compliance). These then analysed against checklist, results compared first cycle. Results Use demonstrated improvement 11 out 15 components, with one component (a documented management plan) remaining 100% compliance. The achieved an 3-point patient identification (+43.7%), dramatic improvements NEWS score/observations (+22.5%), medication review (+26.7%), thromboprophylaxis (+53.4%), examination findings (+45.3%) escalation/DNACPR status (+37.7%). 3 components where performance declined name lead (-8.5%), date (-2.4%) time (-10.6%), most likely due design has been rectified will reaudited ensure improvement. Conclusions Using greatly improves consideration on rounds. This positive implications safety facilitates subsequent ongoing care patient.