Abstract
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.
Original language | English |
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Pages (from-to) | 572-573 |
Number of pages | 2 |
Journal | International Journal of Surgery |
Volume | 8 |
Issue number | 7 |
DOIs | |
Publication status | Published - 1 Sept 2010 |
Research Beacons, Institutes and Platforms
- Manchester Cancer Research Centre