Improving Documentation on the Stroke Unit at Fairfield General Hospital

Poster ID
2947
Authors' names
S.Taylor, A.Nawaz, K.Kawafi
Author's provenances
Department of Stroke Medicine, Fairfield General Hospital, Northern Care Alliance
Conditions

Abstract

AIM

As doctors rotate through the busy stroke unit at Fairfield General Hospital (FGH), there is a chance that some important information may be overlooked while undertaking the daily ward rounds or reviewing a patient on the unit. It is essential that documentation is compliant with the Royal College of Physician’s guidelines for ward round documentations, including the ‘SOAP criteria’ (Subjective, Objective, Assessment and Plan). We designed a ‘Stroke Ward Round Proforma’ to improve efficiency and standardisation of documentation on the stroke ward.

METHODS

The proforma was developed with the support of the Clinical Lead for stroke medicine at FGH. We surveyed junior doctors working in the department before and after introducing the proforma.

RESULTS

After two PDSA cycles, we amended the Proforma to become a ‘Stroke Summary Sheet’ after receiving feedback that daily completion was repetitive in settings outside of HASU (Hyperacute Stroke Unit). 100% of those surveyed reported that the implementation made their work more efficient and consistent.

DISCUSSION

In conclusion, we successfully designed a Stroke Summary Sheet which encapsulates the pertinent information for efficient and standardised reviews of patients in a busy stroke unit. The summary sheet we designed was not used as much as we had hoped nor in the exact way we intended. We identified a few barriers to success - difficulty identifying the sheet amongst paper notes, limited space to document more complex issues and a preference for more traditional documentation. We suggest that a further revision of this tool may improve the functionality.