Introduction: Accurate documentation of the ward round is crucial for continuity of care and is medico-legally mandatory. It is commonly undertaken by inexperienced doctors and standards vary. The aim of the study was to assess whether a teaching session for foundation doctors improved surgical ward round documentation. Materials and methods: A tutorial on ward round documentation was given to all foundation doctors. Ward round entries for all surgical patients were assessed before, 2 weeks after and 8 weeks after the teaching. Data collectors were blinded to the dates of the entries. Entries were given a numerical score based on criteria derived from GMC and RCS guidance. Results: The mean score before teaching was 65%, increasing to 76% (p<0.05) 2 weeks after teaching but falling to 70% at 8 weeks. The greatest improvements were seen in areas that were initially the poorest. There was short term improvement in 6 criteria. 3 criteria showed sustained improvement: time of entry documented (31% to 60%); entry signed (77% to 93%); pager number of author documented (68% to 97%). Conclusion: A dedicated teaching session can improve ward round documentation. To make sustained improvement it may be necessary to repeat the teaching session at regular intervals.
Research Beacons, Institutes and Platforms
- Manchester Cancer Research Centre