Care of the Older People's Service, Royal London Hospital, Bart's Health NHS Trust, London, UK.
Br J Hosp Med (Lond). 2021 Jan 2;82(1):1-6. doi: 10.12968/hmed.2020.0604. Epub 2021 Jan 28.
AIMS/BACKGROUND: The post-take ward round is often the first time that a senior clinician reviews a patient on the acute medical take. Despite this, there is no official guidance regarding structure or documentation of the post-take ward round. The aim of this quality improve project was to develop a ward round proforma specifically tailored to the care of the older people's service to improve quality of documentation and to encourage initiation of the comprehensive geriatric assessment.
An initial audit was carried out assessing the documentation of key information and the initiation of the comprehensive geriatric assessment during the post-take ward round. A proforma was subsequently designed and implemented with the aims of improving the quality of documentation and increasing the number of patients for whom the comprehensive geriatric assessment was started. A repeat audit was conducted to assess the effectiveness of the proforma.
The results demonstrated an improvement in documentation of all key information criteria and an increase in the initiation of the comprehensive geriatric assessment.
Use of a specifically tailored post-take ward round proforma improves the quality and consistency of documentation and encourages the initiation of the comprehensive geriatric assessment.
目的/背景：在接收患者后的病房查房中，上级临床医生通常首次对急性内科患者进行查房。尽管如此，对于接收患者后的病房查房的结构或记录并没有官方指南。本质量改进项目旨在开发一个专门针对老年科服务的查房记录单，以改善记录的质量，并鼓励全面老年评估的开展。
进行了初始审核，评估了在接收患者后的病房查房中关键信息的记录情况以及全面老年评估的开展情况。随后设计并实施了一个记录单，旨在提高记录的质量并增加开展全面老年评估的患者数量。进行了重复审核，以评估记录单的效果。
结果表明，所有关键信息标准的记录质量均得到改善，并且开展全面老年评估的比例也有所增加。
使用专门设计的接收患者后的病房查房记录单可以提高记录的质量和一致性，并鼓励开展全面老年评估。
