Does a Post-take Ward Round Proforma Lead to Sustainable Improvements in Quality of Documentation for Patients Admitted to the Medical Assessment Unit?

Abstract

This study assessed the quality of post-take ward round (PTWR) documentation, specifically looking at twelve criteria, in the medical assessment unit (MAU) prior to, 3- months and 2-years after introducing a PTWR proforma. 216 case records were analysed; 40 prior to, 40 three-months and 146 two-years after introducing the PTWR proforma. There was a significant improvement in eight criteria threemonths after introducing the PTWR proforma. These improvements were sustained two-years later and significant improvements made in a further 3 criteria (1 at p < 0.05 and 2 at p < 0.01).

Surgical ward round checklist: does it improve medical documentation? A clinical review of Christchurch general surgical notes

“…This has led to significant improvement in the documentation of several, but not all, pre‐determined parameters . Findings of improved documentation with proformas have been corroborated in other hospitals in surgical and medical departments.…”