Abstract
Background
Inadequate medical documentation has been associated with a higher rate of adverse events and may have medicolegal consequences. An accurate admission note is critical as it is frequently referred to during inpatient stay, particularly when the patient is acutely unwell and during handover of care.
Aim
We set out to implement a surgical admission proforma and evaluate its impact on the quality of acute surgical admission notes.
Methods
A standardised, structured admission proforma for use with all emergency general surgery patients in a busy model 3 hospital was designed and implemented. Previously, all admission notes were performed freehand. The quality and completeness of admission notes was evaluated both before and after implementation of the proforma over two separate 4-week periods by assessing documentation across 19 criteria.
Results
Two hundred and fifty-one admission notes before proforma implementation and 273 admission notes after implementation were assessed. Proforma uptake was 97%. Documentation improved in all 19 criteria, with statistical significance achieved in 17 of these. These include past medical history, medication lists, allergy status, physical examination findings, blood results, vital signs and management plan. The proforma showed evidence of improved communication with both nursing staff and senior colleagues.
Conclusions
The surgical admission proforma has significantly improved the quality and completeness of admission documentation, ensuring improved patient safety and efficiency of care. Structured admission proformas have a positive impact on patient outcomes, doctors’ performance, hospital efficiency, communication and audit quality control, thus providing multiple clear benefits in comparison to freehand admission notes.
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Data availability
The data that supports the findings of this study is available from the corresponding author upon reasonable request. Data analysis was performed using Strata 14 (StrataCorp, TX)
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Acknowledgements
We thank the surgical, nursing and administrative staff of our hospital.
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Mr. Enda Hannan: study conceptualisation, study design, data collection, data analysis, data interpretation, writing of the article, final approval for submission
Dr. Abrar Ahmad: data collection
Dr. Aoife O’Brien: data collection
Dr. Sinead Ramjit: data collection
Mr. Shahbaz Mansoor: study conceptualisation, study design, final approval for submission
Mr. Desmond Toomey: study conceptualisation, study design, writing of the article, final approval for submission
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Hannan, E., Ahmad, A., O’Brien, A. et al. The surgical admission proforma: the impact on quality and completeness of surgical admission documentation. Ir J Med Sci 190, 1547–1551 (2021). https://doi.org/10.1007/s11845-020-02475-1
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DOI: https://doi.org/10.1007/s11845-020-02475-1