title: A ward round proforma improves documentation and communication.
abstract: This article present the results of an audit cycle which evaluated the quality of inpatient ward round documentation in a busy district general hospital before and after the implementation of a standardized proforma which was specifically designed for trauma and orthopaedic patients. In each cycle, 20 case notes were examined and the data analysed to examine three main areas: Diagnosis, management and/or discharge plan Objective assessments including neurovascular status, weight-bearing status, surgical wound review, observations, results of investigations and decision from the daily trauma meeting Logistics of the documentation such as legibility, date and time, name and grade of the doctor and contact number. This audit demonstrated that using a ward round proforma can significantly enhance the quality of documentation and improve communication between multidisciplinary team members.
authors.affiliation: Specialty Registrar, Department of Trauma and Orthopaedic Surgery, Royal London Hospital, London E1 1BB.
authors.forename: Sulaiman
authors.initials: S
authors.lastname: Alazzawi
authors.affiliation: Specialty Registrar, Department of Trauma and Orthopaedic Surgery, Princess Alexandra Hospital, Harlow, Essex.
authors.forename: Zacharia
authors.initials: Z
authors.lastname: Silk
authors.affiliation: Senior House Officer, Department of Elderly Medicine, Queen's Hospital, Romford, Essex.
authors.forename: Urmila U
authors.initials: UU
authors.lastname: Saha
authors.affiliation: Consultant Trauma and Orthopaedic Surgeon, Department of Trauma and Orthopaedics, Queen's Hospital, Romford, Essex.
authors.forename: Sunil
authors.initials: S
authors.lastname: Auplish
authors.affiliation: Consultant Trauma and Orthopaedic Surgeon, Department of Trauma and Orthopaedics, Queen's Hospital, Romford, Essex.
authors.forename: Sean
authors.initials: S
authors.lastname: Masterson
mesh_terms: D003142:Communication; D004282:Documentation / Q000592:standards*; D006767:Hospitals, District; D006769:Hospitals, General; D006801:Humans; D009985:Orthopedics; D058996:Quality Improvement; D011996:Records; D056164:Teaching Rounds; D014194:Traumatology