Improving the quality of documentation of paediatric post-take ward rounds: the impact of an acrostic.

BACKGROUND

Review of patients' notes while investigating clinical incidents showed a recurring problem of poor documentation of important aspects of the paediatric post-take ward round.

PURPOSE OF THE STUDY

To evaluate the impact of an acrostic (type of mnemonic), created to reflect the aspects of care that should be documented after every ward round, on the completeness of note keeping.

STUDY DESIGN

The acrostic, 'Please Verify Information For Doctors, Please Note Every Plan, was developed in 2010 to make it easy to remember the important aspects of post-take ward round, which are: Problem; Vital signs; Investigations; Fluids; Drugs; Patient/Parental concerns; Nursing concerns; Examination; Plan. The acrostic was introduced to doctors at a teaching session and included in the mandatory induction programme for all new doctors. Impact of use of the acrostic was evaluated in 2011 by audit of case notes before and after its introduction, with re-audit 2 years later. A survey of junior doctors on their attitude to its use was carried out in 2014.

RESULTS

Introduction of the acrostic led to significant improvement in the documentation of problem (84% vs 94%), investigations (26% vs 72%), fluids (16% vs 74%), drugs (26% vs 76%), patient/parental concerns (16% vs 72%) and nursing concerns (4% vs 48%). Most (95% (19/20)) of the junior doctors agreed that the acrostic provided them with an easy format to document important aspects of post-take ward rounds.

CONCLUSIONS

Our patient notes now reflect much more clearly the input of patients and their parents/carers and the involvement of the multiprofessional team.