The surgical admissions proforma: Does it make a difference?

摘要

Admissions records are essential in communicating key information regarding unwell patients and at handover of care. We designed, implemented and evaluated the impact of a standardised surgical clerking proforma on documentation and clinician acceptability in comparison to freehand clerking. A clerking proforma was implemented for all acute general surgical admissions. Documentation was assessed according to 32 criteria based on the Royal College of Surgeons of England guidelines, for admissions before (n?=?72) and after (n?=?96) implementation. Fisher's exact test and regression analysis were used to compare groups. Surgical team members were surveyed regarding attitudes towards the new proforma. Proforma uptake was 73%. After implementation, documentation increased in 28/32 criteria. This was statistically significant in 17 criteria, including past surgical history ( p ?