Abstract
Background: Ward round entries form the backbone of medical documentation, forming the context in which new diagnoses and safe handovers are made. They are also an important legal record that should be clear and up to date. Ward round entries without important information, including vital observations and examination findings, cause ambiguity as to whether these aspects of patient care have been reviewed.
Aims: To ascertain the level of completeness of ward round entries with respect to salient features of patient care. To design and implement a ward round proforma which aids this completeness and ascertain whether an improvement was achieved. Methods: We defined a list of 17 salient aspects of patient care with a group of clinicians of various grades. 139 ward round entries were reviewed for their inclusion prior to the introduction of the proforma and 98 following the introduction.
Results: The introduction of the proforma markedly improved the documentation of all the studied parameters. For example: presenting complaint improved from 48% to 86%; vital observations improved from 82% to 95%; exam findings improved from 66% to 97%. 100% of doctors surveyed found it easy to use and 50% felt that it increased the speed of their round.
Discussion: The proforma was easy to use and aided in communication of patient care between clinicians and teams. As such it improved patient safety as well as efficiency. The proforma was created in such a way that it can be easily transferred to electronic patient records to enable use in a multitude of settings.