Abstract

Background and aim Ward-round documentation is important for clinical communication and patient safety.

Standardized checklists have improved ward-round documentation in surgical and medical settings.

This quality improvement project aimed to introduce a standardized ward round proforma to improve documentation in a UK specialist stroke unit.

Methods

Ward round entries were assessed against internally agreed standardized criteria.

A stroke-specific ward round proforma was designed and introduced with input from the multidisciplinary team.

A repeat audit was performed, including assessment of the use of different proforma sections.

Multidisciplinary team members were invited to provide feedback via an anonymous online survey.

Results

A total of 111 ward round entries were reviewed before the proforma was introduced.

Ninety-five ward round entries were reviewed following introduction of the proforma, and 84.2% of these used the proforma for documentation.

Overall documentation of standardized criteria improved from 48.7% to 62.1% with substantial improvement seen in documentation of neurological examination, presence/absence of mechanical venous thromboembolism prophylaxis, and blood test results.

Multidisciplinary team feedback was positive.

Conclusions

The stroke-specific ward round proforma improved the quality and consistency of documentation in the unit.

An updated proforma was designed using these results and multidisciplinary team feedback.

Citations

Armstrong E J, Carpenter K J (November 27, 2022) A Standardized Ward Round Proforma Improves Documentation in a Specialist Stroke Unit. Cureus 14(11): e31931.

DOI: https://doi:10.7759/cureus.31931

URI: https://www.oxfordhealth.nhs.uk/orka/title/a-standardized-ward-round-proforma-improves-documentation-in-a-specialist-stroke-unit/