The surgical admissions proforma: Does it make a difference?

Abstract

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 < 0.01), medication history (p = 0.03), ADLs (p = 0.02), systems review (p < 0.01), blood pressure (p < 0.01), blood results (p = 0.02) and advice given to the patient (p = 0.02). The proforma remained beneficial after regression analysis accounted for differences in time of day, seniority of the doctor and nights or weekends (coefficient = 0.12 [p < 0.01]). 89% of the surgical team felt the form improved quality of documentation and preferred its use to freehand clerking. 94% felt it was beneficial on the post-take ward-round. Audit quality control was also more reliable with the proforma (inter-observer agreement = 99.3% [κ = 0.997]) versus freehand clerking (97.1% [κ = 0.941]). Our study demonstrates that a standardised surgical clerking proformas improves the quantity and quality of documentation in comparison to freehand clerking, is preferred by health professionals and improves reliability of the audit quality control process.

Do medical admission pro formas ­improve the completeness of documentation? A multisite observational study

“…Similar data has been published previously in a number of other hospital specialties. Preprinted pro formas have increased completeness of documentation in paediatric admissions, 5 asthma admissions, 6 stroke admissions, 7 psychiatry admissions 8 and surgical admissions 9 . In addition, pro formas have been shown to improve the diagnosis of patients admitted with a hand injury, 10 and improve compliance with the Best Practice Tariff among hip fracture patients.…”

Quality of Clinical Notes: Lesson Learned from Elective Surgery Patients Admitted at University Teaching Hospital

“…11, 12 Standardizing entries in clinical notes during the course of care is important for consistency. Structured, agreed upon entries improves documentation.…”

The use of a pro forma to improve quality in clerking vascular surgery patients

“…This review showed that the use of a pro forma improves the quality of clerking documentation in elective surgical patients, and that standardisation of the medical record improved the quality of patient care. [6][7][8][9][10][11][12][13][14][15] Evidence is presented across the audits that the use of a pro forma leads to significantly improved documentation for surgical patients, in areas such as previous medical history and medication history. [7,12,13,15] It has also been shown to significantly improve the completion of VTE assessment.…”

“…[6][7][8][9][10][11][12][13][14][15] Evidence is presented across the audits that the use of a pro forma leads to significantly improved documentation for surgical patients, in areas such as previous medical history and medication history. [7,12,13,15] It has also been shown to significantly improve the completion of VTE assessment. [11] The evidence also supports the argument that the use of a pro forma specifically improves documentation of items considered important by the Royal Colleges that are often missed during clerking documentation.…”