459 Standardised Surgical Admission Proformas: A Quality Improvement Project

Abstract Background “Documentation burden” in a busy healthcare setting is commonly cited cause for suboptimal documentation and its associated adverse implications. While electronic patient records have been heralded as solution, costs with necessary infrastructure may be prohibitive. We designed implemented standardised surgical admission proforma evaluated impact on improving compliance standards documentation. Method Freehand notes consecutive admissions over 4-week period were audited against guidelines produced by the Royal College of Surgeons (England). A structured was introduced 2-week to replace freehand documentation, efficacy subsequently reaudited period. Results total 67 evaluated. Key components such vital signs, medications allergies documented less than 46%, 43% 72% respectively. Additionally, smoking alcohol consumption 40% notes. 51 proformas, 100% uptake, post-intervention. The mean improvement signs 60.0% (SD = 0.11). Documentation existing medications, consumption, status laboratory investigations results improved significantly 46.9%, 43.1%, 40.6% 17.5% 96.1% had identifiable medical council registration numbers. Improvements legibility efficiency also noted. Conclusions Introduction resulted significant improvements quality completeness Concise, legible, accurate fundamental maintaining effective clinical governance, allowing provision safe efficient care.