The surgical admissions proforma: does it make a difference?

Publication date: Available online 7 February 2015 Source:Annals of Medicine and Surgery Author(s): Jasmine Ehsanullah , Umar Ahmad , Kohmal Solanki , Justin Healy , Naim Kadoglou Admissions records are essential in communicating key information regarding unwell patients and at handover of care. We designed, implemented and evaluated the impact of a standardised surgical clerking proforma on documentation and clinician acceptability in comparison to freehand clerking. A clerking proforma was implemented for all acute general surgical admissions. Documentation was assessed according to 32 criteria based on the Royal College of Surgeons of England guidelines, for admissions before (n=72) and after (n=96) implementation. Fisher’s exact test and regression analysis were used to compare groups. Surgical team members were surveyed regarding attitudes towards the new proforma. Proforma uptake was 73%. After implementation, documentation increased in 28/32 criteria. This was statistically significant in 17 criteria, including past surgical history (p<0.01), medication history (p=0.03), ADLs (p=0.02), systems review (p<0.01), blood pressure (p<0.01), blood results (p=0.02) and advice given to the patient (p=0.02). The proforma remained beneficial after regression analysis accounted for differences in time of day, seniority of the doctor and nights or weekends (coefficient=0.12 [p<0.01]). 89% of the surgical team felt the form improved quality of ...
Source: Annals of Medicine and Surgery - Category: Journals (General) Source Type: research