Improving the Documentation Quality of Pediatric Ward Rounds
Background Review of patients' notes while investigating clinical incidents showed a recurring problem of poor documentation of important aspects of the paediatric post-take ward round.
Purpose of the study To evaluate the impact of an acrostic (type of mnemonic), created to reflect the aspects of care that should be documented after every ward round, on the completeness of note keeping.
Study design The acrostic, 'Please Verify Information For Doctors, Please Note Every Plan, was developed in 2010 to make it easy to remember the important aspects of post-take ward round, which are: Problem; Vital signs; Investigations; Fluids; Drugs; Patient/Parental concerns; Nursing concerns; Examination; Plan. The acrostic was introduced to doctors at a teaching session and included in the mandatory induction programme for all new doctors. Impact of use of the acrostic was evaluated in 2011 by audit of case notes before and after its introduction, with re-audit 2 years later. A survey of junior doctors on their attitude to its use was carried out in 2014.
Results Introduction of the acrostic led to significant improvement in the documentation of problem (84% vs 94%), investigations (26% vs 72%), fluids (16% vs 74%), drugs (26% vs 76%), patient/parental concerns (16% vs 72%) and nursing concerns (4% vs 48%). Most (95% (19/20)) of the junior doctors agreed that the acrostic provided them with an easy format to document important aspects of post-take ward rounds.
Conclusions Our patient notes now reflect much more clearly the input of patients and their parents/carers and the involvement of the multiprofessional team.
Most children admitted as emergencies are seen, diagnosed and managed by supervised junior doctors. Care is evaluated, and coordinated care plans are formulated on post-take rounds, led by the supervising consultant paediatrician. These rounds are multidisciplinary and, where possible, parents and carers participate. Much information is shared during these rounds, and decisions are made. These rounds are central to providing effective care and are an important reference point for staff, children and parents. Accurate and complete documentation is clearly important. But this is a task often left to the most junior doctor. Previous studies have shown failure to document key elements of ward rounds in such situations. Documenting all that happens on the paediatric post-take round can be challenging, as so much may be going on during the round that it may appear disorganised. For example, the approach to children has to be adapted to their developmental age; information may become available during the round and paediatricians may have to be opportunistic in choosing when to examine a child. Making sure that decisions and all supporting information are accurately documented is important for several reasons. Children, even those whose stay in hospital is short, may be cared for by several teams of doctors and nurses working shift patterns, and so good documentation of clinical findings, care plans and the views of patients, carers and the multidisciplinary team is necessary for effective continuity of care between teams. In the few cases where care becomes the focus of legal discussion, patient's notes are a source of evidence. Notes should be clear, complete and recorded contemporaneously. If not, care may be compromised. In view of the problems with inadequate documentation, we carried out a study to evaluate whether the introduction of an acrostic (a mnemonic device) improved the completeness of documentation of the paediatric post-take ward round (see Box 1 for definition of mnemonic devices). We carried out case note audit before and after implementation and evaluated if the change was sustainable.
Abstract and Introduction
Abstract
Background Review of patients' notes while investigating clinical incidents showed a recurring problem of poor documentation of important aspects of the paediatric post-take ward round.
Purpose of the study To evaluate the impact of an acrostic (type of mnemonic), created to reflect the aspects of care that should be documented after every ward round, on the completeness of note keeping.
Study design The acrostic, 'Please Verify Information For Doctors, Please Note Every Plan, was developed in 2010 to make it easy to remember the important aspects of post-take ward round, which are: Problem; Vital signs; Investigations; Fluids; Drugs; Patient/Parental concerns; Nursing concerns; Examination; Plan. The acrostic was introduced to doctors at a teaching session and included in the mandatory induction programme for all new doctors. Impact of use of the acrostic was evaluated in 2011 by audit of case notes before and after its introduction, with re-audit 2 years later. A survey of junior doctors on their attitude to its use was carried out in 2014.
Results Introduction of the acrostic led to significant improvement in the documentation of problem (84% vs 94%), investigations (26% vs 72%), fluids (16% vs 74%), drugs (26% vs 76%), patient/parental concerns (16% vs 72%) and nursing concerns (4% vs 48%). Most (95% (19/20)) of the junior doctors agreed that the acrostic provided them with an easy format to document important aspects of post-take ward rounds.
Conclusions Our patient notes now reflect much more clearly the input of patients and their parents/carers and the involvement of the multiprofessional team.
Introduction
Most children admitted as emergencies are seen, diagnosed and managed by supervised junior doctors. Care is evaluated, and coordinated care plans are formulated on post-take rounds, led by the supervising consultant paediatrician. These rounds are multidisciplinary and, where possible, parents and carers participate. Much information is shared during these rounds, and decisions are made. These rounds are central to providing effective care and are an important reference point for staff, children and parents. Accurate and complete documentation is clearly important. But this is a task often left to the most junior doctor. Previous studies have shown failure to document key elements of ward rounds in such situations. Documenting all that happens on the paediatric post-take round can be challenging, as so much may be going on during the round that it may appear disorganised. For example, the approach to children has to be adapted to their developmental age; information may become available during the round and paediatricians may have to be opportunistic in choosing when to examine a child. Making sure that decisions and all supporting information are accurately documented is important for several reasons. Children, even those whose stay in hospital is short, may be cared for by several teams of doctors and nurses working shift patterns, and so good documentation of clinical findings, care plans and the views of patients, carers and the multidisciplinary team is necessary for effective continuity of care between teams. In the few cases where care becomes the focus of legal discussion, patient's notes are a source of evidence. Notes should be clear, complete and recorded contemporaneously. If not, care may be compromised. In view of the problems with inadequate documentation, we carried out a study to evaluate whether the introduction of an acrostic (a mnemonic device) improved the completeness of documentation of the paediatric post-take ward round (see Box 1 for definition of mnemonic devices). We carried out case note audit before and after implementation and evaluated if the change was sustainable.
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