Improving patient safety with consistent documentation of ward rounds
When admitted to UK hospitals, patients are regularly reviewed by the clinical team responsible for their care, and this is usually referred to as a ward round. These rounds are crucial for assessing patient progress and updating the plan of care and discharge.
Whilst there is more consensus regarding best practice documentation upon admission and discharge, there is significant variation on what clinicians record as a ward round entry. When staff record on paper, or electronically in free text boxes, there will always be variation. Where there is variance, there is the opportunity for error. For example, it can cause confusion and delays in treatment if important decisions and plan of care are not visible to the wider team caring for the patient.
NHS Improvement recently issued guidance for best practice in running and documenting ward rounds. These resources are designed to help Trusts adopt best practices to improve patient safety. Using these tools will help hospitals implement standard templates. For example, it suggests consistent ward round items for review, prompting team members to set and update a discharge date, or determine when to move from IV to oral antibiotics.
Consistency in documentation provides a safety net, helping clinicians make important decisions and remember steps required for discharge planning. Most importantly, dependable recording methodology ensures other team members can find this information. This is becoming ever more crucial as clinical staff work variable shifts, which impacts continuity of care.
Configuration within an electronic patient record (EPR) lends itself to prompting clinicians to check all the key parameters, record decisions and update plans during the ward round. We already have a number of our hospitals benefitting from using various types of structured documentation precisely for this purpose. For example, a junior doctor who recently started using a ward round note in Allscripts Sunrise™ EPR said:
“It took some getting used to initially but it provides a safety net when you are on a busy ward round, ensuring that all the key parameters are checked.”
It is true that documenting structured data on a busy ward round has the potential to slow down the clinicians. However, reliable documentation and clear evidence of decision making can save time. Because NHS Improvement has re-visited and offered standard guidance for ward rounds, we now have an approved view of what documentation should look like. This progression of clinical documentation standards can only be a good thing for patient care.