The surgical admission proforma: the impact on quality and completeness of surgical admission documentation.

BACKGROUND

Inadequate medical documentation has been associated with a higher rate of adverse events and may have medicolegal consequences. An accurate admission note is critical as it is frequently referred to during inpatient stay, particularly when the patient is acutely unwell and during handover of care.

AIM

We set out to implement a surgical admission proforma and evaluate its impact on the quality of acute surgical admission notes.

METHODS

A standardised, structured admission proforma for use with all emergency general surgery patients in a busy model 3 hospital was designed and implemented. Previously, all admission notes were performed freehand. The quality and completeness of admission notes was evaluated both before and after implementation of the proforma over two separate 4-week periods by assessing documentation across 19 criteria.

RESULTS

Two hundred and fifty-one admission notes before proforma implementation and 273 admission notes after implementation were assessed. Proforma uptake was 97%. Documentation improved in all 19 criteria, with statistical significance achieved in 17 of these. These include past medical history, medication lists, allergy status, physical examination findings, blood results, vital signs and management plan. The proforma showed evidence of improved communication with both nursing staff and senior colleagues.

CONCLUSIONS

The surgical admission proforma has significantly improved the quality and completeness of admission documentation, ensuring improved patient safety and efficiency of care. Structured admission proformas have a positive impact on patient outcomes, doctors' performance, hospital efficiency, communication and audit quality control, thus providing multiple clear benefits in comparison to freehand admission notes.