Lost in transcription - how accurately are we documenting the surgical ward round?

BACKGROUND

Ward rounds are crucial to providing high-quality patient care in hospitals. Ward round quality is strongly linked to patient outcomes, yet ward round best practice is severely underrepresented in the literature. Accurate and thorough ward round documentation is essential to improving communication and patient outcomes.

METHODS

A prospective observational cohort study was performed by reviewing 135 audio-visual recordings of surgical ward rounds over 2 years at two hospitals. Recordings were transcribed, and an external reviewer stratified discussion points as Major, Minor, or Not Significant. Discussion was compared to the ward round note to assess the accuracy of documentation based on bedside discussion. The primary endpoint was the accuracy of Major discussion in the patient case notes. Secondary objectives involved investigating variables that may have impacted accuracy (e.g., patient age, sex, length of stay in hospital, and individual clinicians).

RESULTS

Nearly one third (32.4%) of important (Major) spoken information regarding plans and patient care in the ward round was omitted from the patients' written medical record. Further, 11% of patient case notes contained significant errors. Patient age (P = 0.04), the day of the week on which the ward round occurred (P = 0.05) and who the scribing intern was (P ≤ 0.001) were found to impact documentation accuracy. There was a large variation in interns documenting ability (35.5%-88.9% accuracy).

CONCLUSIONS

This study highlighted that a significant portion of important discussion conducted during the ward round is not documented in the case note. These results suggest that system-wide change is needed to improve patient safety and outcomes.