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Improving documentation of a surgical ward round: A quality improvement project
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Journal of Health & Medical Informatics

ISSN: 2157-7420

Open Access

Improving documentation of a surgical ward round: A quality improvement project


14th World Congress on Healthcare & Technologies

July 22-23, 2019 | London, UK

Jin Quan Nataniel Tan and Katherine MacFarland

University College Hospital, UK

Posters & Accepted Abstracts: J Health Med Informat

Abstract :

Statement of the Problem: Surgical ward rounds are often rushed, which may result in poor quality documentation. NICE guidelines require ??every record to be dated and signed??. Since the introduction of the EPIC system at UCLH, patient documentation is completely electronic. EPIC allows personalization of ward round templates that increase efficiency of ward rounds and allow automatic population of patient identifiers.

Methods: Over seven weeks, a ward round template was disseminated to 13 members of the surgical team (6 upper gastrointestinal, 6 colorectal, 1 gynecology). Users were sent formal surveys about the quality of the documentation and time efficiency of documentation, rating this on a score from 0-10, with 10 representing ??strongly agree??. Informal verbal feedback was also collected from six registrars (ST4-ST8), as well as two consultants. Feedback was adopted, and Version 2 was released. The same feedback cycle was repeated.

Results: For Version 1, users felt that the template improved the ward round process. Although users ??strongly agreed?? that the template pulled through ALL the information needed for the ward round, they only ??agreed?? that the template pulled through ONLY the information needed for the ward round. In Version 2, information was populated more concisely with SmartPhrases within EPIC. Version 2??s feedback reflected this, with 9/10 being given to quality and efficiency of documentation. More users strongly agreed that the template pulled through ONLY the information needed for the ward round.

Conclusions: The two project cycles highlighted an area for improvement in ward round documentation. Templates have had positive effects on efficiency and quality of documentation. This has implications on patient safety, as clearer plans are communicated between members of the multi-disciplinary team. Further opportunities include expanding the survey to other members of the multi-disciplinary team, and potentially standardizing this surgical ward round template for all surgical teams.

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