This can be useful information for the nurses and medical team working in discontinuous shift patterns to think about and discuss on the daily ward round. After the initial audit cycle, a ward round proforma was introduced using the above headings and re-audited over a seven day period. The pre-intervention arm contained 50 patients and the post intervention arm contained 47. Results. Audit results were presented at the department meeting and a Trauma Meeting/Post-Take Ward Round Proforma was implemented. Long term ICU patient pro-forma ward round log v1.doc — Microsoft Word Document, 67Kb Document Actions Does a post-take ward round proforma have a positive effect on completeness of documentation and efficiency of information management? They will start to notice the subtle changes in their baby's condition. 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. 18% of all cases did not have a proforma. The aim of this quality improvement project was to determine whether introducing a standardised ward round pro-forma would result in improved documentation standards and increase the consideration of a number of selected areas (thromboprophylaxis, oxygen prescription, fluid status, antibiotic review, ceiling of treatment, DNACPR status, NEWS etc). The surgical wards use paper-based records and so the proforma was printed out on stickers and then attached to the notes once filled out. 1.6. 88% of patients seen had a proforma completed. structuring ward rounds: preparation, scheduling and post-round review with allocation of tasks; patient participation: preparing patients in advance and promoting shared decision-making and self-management; protecting vulnerable patients, with nurses and junior doctors ensuring that their needs are articulated and addressed Ward Round Documentation M. Tips! 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. > To engage all members of the ward-round team in the process, individual roles and 3 Challenges Multidisciplinary working Recommendations for effective team working > Staffing issues and other adverse factors should be identified before the ward round. ward round proforma sheet during the w ard round, we. Write everything that’s said by the consultant/patient Different consultants have different preferences about how they like things written (the above is an example) All members of the surgical teams were encouraged to fill out the proforma for the post-acute consultant ward round (PACWR). Daniel N. Wright. A prospective re-audit of 50 cases revealed that patients not seen on a PTWR decreased to 18%; 4% of these were weekend admissions. A standardized ward round checklist (adhesive proforma sticker, PFS) was introduced at our institution in 2013 to improve documentation by junior doctors. or a structured proforma for written forms of communication. Leave enough space for each section and write things in the relevant section as they are said (often won’t be in order!) Health Informatics Journal 2009 15: 2, 86-94 Download Citation. A proforma was introduced with the goal of improving documentation (Figure 1). Ward round proforma. found that the aver age time taken to write up the pro-forma for each patient w as 1 minute 9 seconds and that. A standardized ward round checklist (adhesive proforma sticker, PFS) was introduced at our institution in 2013 to improve documentation by junior doctors. 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