Atluri Lakshmi Malvika, Chong Kenneth Jit, Zumot Maya, Kantamaneni Ketan, Kondi Suresh, Bakka Havil Stephen Alexander, Kantamneni Reshmitha
General Surgery, Royal Blackburn Hospital, Blackburn, GBR.
General Surgery, Royal Salford Hospital, Manchester, GBR.
Cureus. 2024 Nov 16;16(11):e73823. doi: 10.7759/cureus.73823. eCollection 2024 Nov.
Aim Effective documentation of critical clinical information is vital for patient safety and timely discharges. Ward rounds (WRs) are crucial for multidisciplinary assessments and care planning. Current emergency surgical WR documentation is inconsistent; therefore, this study will implement a structured WR template adapted from the Royal College of Surgeons of Edinburgh's "Surgical Assessment for Emergencies Ward Round Tool" (SAFE) to address these shortcomings. Methods A retrospective review of case note entries from surgical WRs was conducted between April 1 and April 14, 2024. A total of 500 random WR entries were reviewed. Recommended standards of WR documentation were obtained from the SAFE tool. The overall documentation of 14 parameters was checked. The WR entries from the weekends have been excluded from the study. After the implementation of the template, another review of 500 case note entries was conducted between October 1 and October 14, 2024. Results The only consistently documented parameter is the name of the consultant (97%). Parameters such as VTE prophylaxis (5%), examination findings (18%), NBM/nutrition (20%), the patient's current clinical status (30%), and NEWS/observations (35%) were very suboptimally documented. Management plans and discharge planning were not efficiently detailed (<30%). All the parameters that were reviewed post-implementation of a WR template were documented, with the average being 88.14%, thus demonstrating a significantly high impact. Conclusion A modifiable documentation template was created to improve and standardize the General Surgery WR documentation. The implementation of a WR template has enhanced the documenting of essential elements of patient care. It enhances patient safety as well as communication and documentation, ensuring that critical issues are not overlooked during patient assessments on WRs.
目的 有效记录关键临床信息对于患者安全和及时出院至关重要。病房查房（WRs）对于多学科评估和护理计划至关重要。当前急诊外科病房查房记录不一致；因此，本研究将采用爱丁堡皇家外科医学院的“急诊病房查房手术评估工具”（SAFE）改编的结构化病房查房模板来解决这些不足。方法 对2024年4月1日至4月14日外科病房查房的病例记录条目进行回顾性审查。共审查了500条随机的病房查房记录。从SAFE工具中获取病房查房记录的推荐标准。检查了14个参数的总体记录情况。周末的病房查房记录被排除在研究之外。在实施模板后，于2024年10月1日至10月14日对另外500条病例记录条目进行了审查。结果 唯一记录一致的参数是会诊医生的姓名（97%）。诸如静脉血栓栓塞预防（5%）、检查结果（18%）、禁食/营养（20%）、患者当前临床状况（30%）以及国家早期预警评分/观察结果（35%）等参数的记录非常不理想。管理计划和出院计划没有得到有效详细记录（<30%）。在实施病房查房模板后审查的所有参数都有记录，平均记录率为88.14%，因此显示出显著的高影响。结论 创建了一个可修改的记录模板，以改进和规范普通外科病房查房记录。病房查房模板的实施增强了患者护理基本要素的记录。它提高了患者安全以及沟通和记录水平，确保在病房查房患者评估期间关键问题不会被忽视。
