surgery-and-ENT-2016_scientifictracks-abstracts

Volume 6, Issue 6(Suppl)

Surgery Curr Res

ISSN: 2161-1076, an open access journal

Page 30

Notes:

Surgery & ENT 2016

November 07-08, 2016

conferenceseries

.com

Surgery & ENT

November 07-08, 2016 Alicante, Spain

International Conference and Exhibition on

An audit of documentation during surgical ward rounds

Mariyah Selmi, Aaron Smith, Andrew Madden

and

Salman Saad

Pennine Acute NHS Hospital Trust, UK

Background:

Surgical ward rounds are generally fast paced. With a quick patient turn over, key information regarding pre/post-

operative care as well as nutrition status often gets missed. Documentation is routinely done by ward based F1 doctors who have had

little involvement in management. If seniors are unavailable, omissions in documentation can lead to detrimental outcomes for the

patients, such as unnecessary antibiotics/dietary restrictions. The patients’ notes provide a record of on-going clinical issues and serve

as a medico-legal document. Therefore, the need for notes to be thorough and legible with a clear indication to all MDT members

regarding future care is paramount.

Aim:

Aim of this study is to quantify the information documented during ward rounds across the general surgical wards and its effect

on patient care.

Method:

The last ward round entry in the patients notes was analyzed against 12 parameters chosen by MDT members. This included

medicolegal aspects: Dates and time, patient identifier, signature with GMC number of doctor, discussion with patient noted and

overall legibility; as well as patient review aspects: Current issues, working diagnosis, plan based on current condition, medication

review, dietary requirement review and estimated discharge date with follow up instructions.

Results:

A total of 47 entries were analyzed, medico-legal aspects of documentation were above 79%. Medication and diet were only

reviewed in 36% of cases with clinical details only being explained to the patients in 6% of cases.

Conclusion:

Lack of clear documentation may have led to poor patient outcomes and difficulty for other team members to provide

care. The introduction of a new pro-forma prompting daily review of the key areas has shown a vast improvement in documentation

and communication between staff and patients. Questioning and reviewing these areas has also provided a learning opportunity with

positive feedback from junior doctors.

Biography

Mariyah Selmi is a 3 foundation trainee with a keen interest in quality improvement and patient safety.

Mariyah Selmi et al., Surgery Curr Res 2016, 6:6(Suppl)