Use of a dedicated admission clerking proforma improves documentation and adherence to national standards

Abstract

Background: Good quality documentation that is comprehensive and coherent improves patient care, helps minimise clinical errors, and is a key safety matter. In our T&O unit, patient clerking is completed on lined continuation paper which results in a lack of format and standardisation, and is prone to omission of key elements within the history and examination.

Aims & Objectives:

1.     Audit adherence of clerking documentation completed on lined continuation paper to standards set by Royal College of Surgeons and Professional Records Standards Body.

2.     Determine whether a dedicated clerking proforma improves compliance to these standards.

Methods: Case notes of 30 consecutive patients admitted to our T&O department from 1^st February 2020 were reviewed prospectively. A 38 item checklist was devised from the standards to assess clerking documentation. Following introduction of a dedicated clerking proforma, 30 additional consecutive patients' notes were assessed from 1^st December 2020 using the original checklist. Results before & following implementation of the proforma were compared. Furthermore, various healthcare professionals (HCPs) were surveyed about current practices and attitudes to clerking practices and use of a proforma.

Results: The proforma outperformed in 32 items (84%). The greatest improvements were seen in social history (93% versus 27%); investigations, plan and diagnosis (77% versus 35%); patient details (80% versus 60%); presenting complaint, past medical and other history (92% versus 62%); musculoskeletal examination (93% versus 69%). 100% of ten HCPs surveyed believed the clerking proforma would ease their duties, improve quality of documentation, and preferred a structured proforma to lined paper.

Conclusions: This audit has identified a low compliance to national documentation standards for patient clerking when lined continuation paper is used. This was improved with the use of a dedicated admissions proforma and we recommend other T&O departments to implement their use if not already in existence.