From the Department of Trauma and Orthopaedic Surgery, University Hospital Waterford.
J Patient Saf. 2021 Dec 1;17(8):553-556. doi: 10.1097/PTS.0000000000000678.
Thorough documentation is of utmost importance in a patient hospital experience. It forms an accurate record of an inpatient stay, facilitates handover between medical colleagues, and is also a legal document. Medical notes tend to be detailed and insightful on admission, but the daily ward round notes have often fallen short of expectation. With most patient records entered by junior level of staff, it is important to ensure that adequate documentation occurs.
We analyzed notes entered in patient charts at set periods and compared them against standards set out in the Royal College of Surgeons Ireland and England, as well as Medical Council guidelines from the two countries. After this, a pro forma was established to standardize the medical record keeping on patient ward rounds. Compliance with guidelines was assessed by comparing notes before introduction of the pro forma and after their introduction.
Before its introduction, 0% of notes fulfilled the full criteria selected for the pro forma documentation. After intervention, there was a good initial response, with notes capturing an average 86% of the required information. A reaudit of compliance 2 months after introduction showed a 9% decrease of information completeness to 75%.
Introduction of a pro forma for the documentation of daily ward rounds improved compliance of ward round notes when compared with internationally recognized guidelines, with no additional time required during ward rounds. Despite improved compliance, continued effort is needed to achieve a better standard of care.
在患者的住院经历中，全面的记录至关重要。它是住院期间的准确记录，有助于同事之间的交接，也是一份法律文件。入院记录通常详细而有见地，但日常病房巡视记录往往不尽如人意。由于大多数患者记录都是由初级工作人员输入的，因此必须确保进行充分的记录。
我们在设定的时间段内分析了患者病历中的记录，并将其与爱尔兰皇家外科学院和英格兰的标准以及两国医学委员会的指南进行了比较。在此之后，我们制定了一份表格，以规范患者病房巡视的病历记录。通过比较引入表格前后的记录，评估对指南的遵守情况。
在引入表格之前，没有任何记录完全符合表格记录的全部标准。干预后，记录有了良好的初步反应，平均记录了所需信息的 86%。引入表格两个月后的再次审核显示，信息完整性下降了 9%，降至 75%。
与国际认可的指南相比，引入日常病房巡视记录表格显著提高了病房巡视记录的合规性，且无需在病房巡视期间额外花费时间。尽管合规性有所提高，但仍需继续努力，以达到更好的护理标准。
