title: Surgical ward round checklist: does it improve medical documentation? A clinical review of Christchurch general surgical notes.
abstract: BACKGROUND
  Poor documentation of medical notes and plans not only adversely affects patient management but also has medico-legal implications. A standardized ward round checklist (adhesive proforma sticker, PFS) was introduced at our institution in 2013 to improve documentation by junior doctors. We aimed to examine the current pattern of PFS documentation (2 years after its introduction) and to identify which fields, if any, have been the most problematic to complete.
  
  
  METHODS
  Notes of all current general surgical inpatients admitted to Christchurch Public Hospital on or before the two study days were reviewed. All information written in the PFS, regardless of accuracy, authorship or completeness, was recorded. Documentation of the various PFS fields was classified as well documented (completed in >80% of PFS), inadequate (40-80%) or minimal (<40%).
  
  
  RESULTS
  Four hundred and seventy-nine PFS were reviewed. Most fields in the PFS were documented to an adequate level (i.e. >80%). Problematic fields identified were dietary plans, diagnosis, national health index number, estimated date of discharge and the patient's first name. Notes of patients on outlying ward contained significantly fewer PFS compared with home-ward patients' notes (0.71 PFS/day versus 1.21 PFS/day, respectively, P < 0.001).
  
  
  CONCLUSIONS
  Our study has shown generally adequate patterns of medical note documentation in the General Surgery service. Certain fields remain challenging to document accurately. The proposed modified PFS was designed to help rectify this; electronic data record may be the step forward, however. It is hoped that other institutions in Australasia would benefit from our experience.
authors.affiliation: Colorectal Unit, Christchurch Public Hospital, Christchurch, New Zealand. yassar.alamri@nzbri.org.|Department of Medicine, New Zealand Brain Research Institute, Christchurch, New Zealand. yassar.alamri@nzbri.org.
authors.forename: Yassar
authors.initials: Y
authors.lastname: Alamri
authors.affiliation: Colorectal Unit, Christchurch Public Hospital, Christchurch, New Zealand.|Department of General Surgery, University of Otago, Christchurch, New Zealand.
authors.forename: Frank
authors.initials: F
authors.lastname: Frizelle
authors.affiliation: Department of Ophthalmology, Al-Nahdha Hospital, Muscat, Oman.
authors.forename: Haitham
authors.initials: H
authors.lastname: Al-Mahrouqi
authors.affiliation: Colorectal Unit, Christchurch Public Hospital, Christchurch, New Zealand.|Department of General Surgery, University of Otago, Christchurch, New Zealand.
authors.forename: Tim
authors.initials: T
authors.lastname: Eglinton
authors.affiliation: Department of General Surgery, University of Otago, Christchurch, New Zealand.
authors.forename: Ross
authors.initials: R
authors.lastname: Roberts
mesh_terms: D019983:Guideline Adherence; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data*; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D008505:Medical Staff, Hospital; D009520:New Zealand; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D013531:Surgicenters / Q000706:statistics & numerical data*
keywords: documentation; medical note; quality and safety; surgical ward round