Background: Accurate and complete documentation on admission is essential to communicate essential clinical information and for medicolegal purposes. It is also important for ensuring accurate Hospital In-Patient Enquiry (HIPE) data collection and accurately demonstrating the complexity of work performed by an acute surgical service. We set out to design and implement a surgical admission form and evaluate its impact on the quality and completeness of acute surgical admission notes.
Methods: We designed and implemented a structured surgical admission proforma for acute admissions in a busy model 3 hospital. Prior to this, all surgical admissions were performed by free-hand documentation. Documentation was assessed based on 32 predetermined criteria both before and after implementation of the proforma over two separate four week periods.
Results: Two hundred and fifty-one admission notes before implementation and 273 admission notes after implementation were assessed. Proforma uptake was 97%, with improved documentation in all 32 criteria. These include past medical history, medication lists, allergy status, physical examination findings, blood results, vital signs and senior review.
Conclusions: The surgical admission proforma has led to significant improvement in both the quality and completeness of clinical notes for acute surgical admissions compared to free-hand documentation. This leads to greater patient safety, better communication, more accurate HIPE data and is important for medicolegal purposes.
