Quality of Surgical Ward Rounds in a District General Hospital: an audit

Abstract Aims The fast-paced surgical ward round, alongside numerous competing distractions and demands, can result in poor rounds and subsequent imperfect documentation. This carries significant medico-legal implications. This audit assessed the standard of surgical ward round documentation at a district general hospital, against Royal College and other published guidelines. Methods A retrospective data collection of adult general surgical patients was undertaken over a period of eight weeks. We excluded bank holiday, weekends and paediatric cases. Documentation during ward rounds in patient notes were analysed and compared against the guidelines. Results 166 patient notes were included. Percentage compliance was assessed as a total, minus cases where not applicable. Good compliance ( > = 75%) was achieved in the majority of data points, including: date (100%), time (83%), ward round lead (99%), legibility (88%), early warning score (78%), current issues (80%) and management (100%). Poor compliance ( < = 25%) was seen in: presenting complaint (25%), fluid balance (16%), intravenous fluid review (21%), catheter review (23%), radiology results (25%), urinalysis (4%), beta HcG (0%), drug chart review (23%), antibiotic review (15%), assessment of venous thrombo-embolic risk (0%) and ceiling of care (1%). Conclusion Accurate, clear and complete documentation is crucial for patient safety and continuity of care, as well as for medico-legal reasons. This study shows there are several areas requiring improvement. The authors propose a proforma including the essential criteria to be integrated into the daily ward rounds.