Does a post-take ward round proforma have a positive effect on completeness of documentation and efficiency of information management?

摘要

The post-take ward round (PTWR) involves the assessment of the latest intake of patients into the hospital. At a busy 400-bed city hospital it had been noted that PTWR notes had, in some cases, become overly brief and uninformative. Previous research had shown that proformas can improve the completeness of the records. So a new proforma was designed and introduced. Its impact on completeness of information was assessed by carrying out an audit of PTWR notes both with and without the proforma. The results showed statistically significant improvements in documentation when the proforma was used. They also showed an improvement in areas of efficiency of record management: for example, the proforma reduced the time taken to retrieve information from the notes, and most users said it saved them time recording in the notes and assimilating information and helped them to speed up patient transfers.