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

Alamri, Yassar; Frizelle, Frank; Al-Mahrouqi, Haitham; Eglinton, Tim; Roberts, Ross

doi:10.1111/ans.13425

Cited by 15 publications

(27 citation statements)

References 15 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Comprehensive WR checklists introduced in the past, when implemented, have been found to take on average 12 min per patient for completion [ 30 ]. A recent study by Alamri et al [ 68 ] proposed a modified proforma in order to improve documentation as well as serve as important prompts during fast-paced surgical ward rounds (Fig. 4 ).…”

Section: Resultsmentioning

confidence: 99%

“…Key ingredients in surgical checklists include: patient details, members of the multidisciplinary team, bedside patient consultation, history and examination findings, review of drains/tubes/lines, charts and medical investigations, documentation, estimated discharge date and presence of relatives/relevant discussions (Fig. 5 ) [ 68 , 69 ]. Indeed with advances in electronic patient records, surgical ward round templates can be introduced to ensure standardization and optimization of patient care—variations of these proformas can then be adjusted to suit the specifics in each specialty.…”

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

“The Longest Way Round Is The Shortest Way Home”: An Overhaul of Surgical Ward Rounds

et al. 2017

View full text Add to dashboard Cite

BackgroundWard rounds, a keystone of hospital surgical practice, have recently been under the spotlight. Poor-quality ward rounds can lead to a greater number of adverse events, thereby cascading to an increased financial strain on our already burdened healthcare systems. Faced with mounting pressures from both outside and inside health organizations, concerted efforts are required to restore it back into prominence where it can no longer take a backseat to the other duties of a surgeon.MethodsThe nucleus of this narrative review is derived from an extensive literature search on surgical ward rounds.ResultsIn this review, we focus on the need for reforms, current characteristics of surgical ward rounds, obstacles encountered by competing interests and proposed solutions in delivery of effective ward rounds that can meet with newly laid guidelines.ConclusionWard rounds should be standardized and prioritized to improve patient care.

show abstract

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

“The Longest Way Round Is The Shortest Way Home”: An Overhaul of Surgical Ward Rounds

et al. 2017

View full text Add to dashboard Cite

show abstract

“…31 Post-follow-up surgical ward round proforma also improves recording quality. 25 Dolan et al, confirmed the use of proforma in the emergency surgery ward. 32…”

Section: Discussionmentioning

confidence: 96%

“…24 Several studies have shown that case studies alone were not enough to eradicate the documentation errors. 25-29 In these studies, only specific problems with the recording of medical data have been investigated and few studies have been conducted on the education of residents and all aspects of documentation. Also there is a gap on training issues in previous studies.…”

Section: Introductionmentioning

confidence: 99%

The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences

et al. 2017

View full text Add to dashboard Cite

Introduction: Medical records contain valuable information about a patient's medical history and treatment. Patient safety is one of the most important dimensions of health care quality assurance and performance improvement. Completing the process of documentation is necessary to continue patient care and continuous quality improvement of basic services. The aim of the present study was to evaluate the effect of medical recording education on the quantity and quality of recording in gynecology residents of Tabriz University of Medical Sciences. Methods: This study is a quasi-experimental study and was conducted at Al-Zahra Teaching Hospital, Tabriz, Iran, in 2016. Thirty-two second through fourth year gynecologic residents of Tabriz University of Medical Sciences who were willing to participate in the study were included by census sampling and participated in training workshop. Three evaluators reviewed the residents’ records before and after training course by a checklist. Statistical analyses were performed using SPSS 13 software. P-values less than 0.05 were considered statistically significant. Results: The results showed that before the intervention, there were significant differences in the quantity of information status among the evaluators and no significant difference was observed in the recording of qualitative status. After the workshop, among the 3 evaluators, there were also significant differences in the quantity of data recording status; however, no significant change was observed in recording of qualitative status. Conclusion: The study findings revealed that a sectional training course of correct and standardized medical records has no effect on reforming the process of recording.

show abstract

“…Checklists build good habits and improve work organization among resident physicians and young specialist physicians [7].…”

Section: Introductionmentioning

confidence: 99%

Checklist in colorectal surgery – proposal of experts of the Polish Club of Coloproctology and National Consultant in general surgery

et al. 2017

View full text Add to dashboard Cite

A checklist is a collection of information that helps reduce the risk of failure due to limitations in human memory and attention. In surgery, the first Surgical Safety Checklist (SSC), created under the supervision of WHO (World Health Organization), was established in 2007 and covers three stages related to the patient's stay in the operating theater and operation: 1. Prior to initiation (induction) of anesthesia; 2. before cutting the skin; 3. before the patient leaves the operating room Colorectal surgery is particularly at high risk for complications and relatively high mortality. Elimination or, more likely, reducing the risk of complications by standardizing perioperative procedures may be particularly important in this group. The introduction of "dedicated" colorectal checklist surgery seems to be justified. The checklist proposed by the authors in colorectal surgery is divided into four stages, in which conscientious completion of checklists is intended to reduce the potential risk of complications due to hospitalization and surgical treatment. The presented checklist is obviously not closed, as a new publications or recommendations appear, some points may be modified, new issues may be added to the checklist. At present, however, it is a tool considering the well-known and confirmed elements of intraoperative procedures, the compliance of which may significantly reduce the rate of adverse events or surgical complications.

show abstract

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

Abstract: Background: Poor documentation of medical notes and plans not only adversely affects patient management but also has medico-legal implications. A standardized ward round checklist (adhesive proforma sticker, PFS) was introduced at our institu-

Cited by 15 publications

References 15 publications

“The Longest Way Round Is The Shortest Way Home”: An Overhaul of Surgical Ward Rounds

“The Longest Way Round Is The Shortest Way Home”: An Overhaul of Surgical Ward Rounds

The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences

Checklist in colorectal surgery – proposal of experts of the Polish Club of Coloproctology and National Consultant in general surgery

Contact Info

Product

Resources

About