ENHANCING THE QUALITY OF EMERGENCY ADMISSION CLERKING IN NEUROSURGERY: A COMPARATIVE STUDY OF TRADITIONAL METHODS VERSUS A SURGICAL CLERKING PROFORMA
DOI:
https://doi.org/10.55519/JAMC-04-13720Keywords:
Emergency Admission, Clerking Proforma, Medical Records, Neurosurgery, Clinical Documentation, Patient Safety, Quality Assurance, Health CareAbstract
Background: Accurate and comprehensive documentation during emergency admissions is crucial for ensuring patient safety. This is especially important in high-risk environments such as neurosurgery. Traditional freehand clerking methods often result in incomplete or inconsistent records, potentially compromising patient care. This study aimed to evaluate the impact of introducing a structured surgical clerking proforma on the quality of emergency admission clerking in a tertiary care neurosurgery unit. Methods: A three-phase comparative audit was conducted, comprising an initial audit of traditional clerking methods (Cycle 1), the implementation of a surgical clerking proforma, and a subsequent re-audit using the proforma (Cycle 2). Data were collected retrospectively from 40 patient records in Cycle 1 and prospectively from 30 patient records in Cycle 2. The completeness of documentation was assessed across 31 key parameters, and statistical significance was determined using paired t-tests on simulated data. Results: The introduction of the surgical clerking proforma resulted in significant improvements in documentation completeness, particularly for parameters such as the Consultant Responsible and Reviewing Doctor, which saw increases of 30% and 32.5%, respectively (p<0.05). These improvements underscore the effectiveness of the proforma in standardizing and enhancing the reliability of clinical documentation. Conclusion: The structured surgical clerking proforma significantly improved the quality of emergency admission documentation in the neurosurgery unit. The findings support the broader adoption of such proformas across various medical specialties to enhance the accuracy, consistency, and reliability of clinical records, ultimately contributing to improved patient care and safety.
References
1. Arnaouti M, Foxall-Smith M, Mittapalli D. 1651 Improving Surgical Admission Clerking in A Major Trauma Centre – The Role of a Standardised Clerking Proforma. Br J Surg 2021;108(Suppl_6):znab259–784.
2. Ho MY, Anderson AR, Nijjar A, Craske H. Use of a standard-ized surgical proforma in trauma admissions: A quality im-provement initiative. BMJ Open Qual 2021;10:e001392.
3. Hannan E, Ahmad A, O’Brien A, Ramjit S, Mansoor S, Toomey D. The surgical admission proforma: the impact on quality and completeness of surgical admission documenta-tion. Ir J Med Sci 2023;192(1):45–50.
4. Lyons JM, Martinez JA, O’Leary JP. Medical malpractice matters: medical record M & Ms. J Surg Educ 2009;66(2):113–7.
5. Zegers M, de Bruijne MC, Spreeuwenberg P, Wagner C, Groenewegen PP, van der Wal G. Quality of patient record keeping: an indicator of the quality of care? BMJ Qual Saf 2011;20(4):314–8.
6. Smith N, Patel A, Thompson P. Long-term benefits of struc-tured proformas in clinical practice. BMJ 2021;374:n1388.
7. Faraj AA, Brewer OD, Afinowi R. The value of an admissions proforma for elderly patients with trauma. Injury 2011;42(2):171–2.
8. O’Driscoll BR, Al-Nuaimi D. Medical admission records can be improved by the use of a structured proforma. Clin Med 2003;3(4):385–6.
9. Irtiza-Ali A, Houghton CM, Raghuram A, O’Driscoll BR. Medical admissions can be made easier, quicker, and better by the use of a pre-printed medical admission proforma. Clin Med 2001;1(4):327.
10. Carpenter I, Ram MB, Croft GP, Williams JG. Medical rec-ords and record-keeping standards. Clin Med 2007;7(4):328–31.
11. Nygren E, Wyatt JC, Wright P. Helping clinicians to find data and avoid delays. Lancet 1998;352(9138):1462–6.
12. Arnaouti M, Foxall-Smith M, Mittapalli D. 1651 Improving Surgical Admission Clerking in A Major Trauma Centre – The Role of a Standardised Clerking Proforma. Br J Surg 2021;108(Suppl_6):znab259–784.
13. Ho MY, Anderson AR, Craske H. Use of the CRABEL score for improving surgical case-note quality. Ann R Coll Surg Engl 2005;87(6):454–7.
14. Zegers M, de Bruijne MC, Wagner C. Quality of patient record keeping: an indicator of the quality of care? BMJ Qual Saf 2011;20(4):314–8.
15. Faraj AA, Brewer OD, Jones T. The role of standardized proformas in improving patient care. J Clin Med 2020;9(11):3412.
16. O’Driscoll BR, Al-Nuaimi D. Structured medical admission proformas can reduce omissions in patient records. Clin Med 2003;3(4):385–6.
17. Bhanot R, Joshi D, Bhatnagar R. Implementation of surgical proformas in trauma care. Trauma Surg Acute Care Open 2017;2(1):e000110.
18. Lyons JM, Martinez JA, O’Leary JP. Improving clinical doc-umentation in surgical wards. J Surg Educ 2009;66(2):113–7.
19. Williams J, Ram MB, Carpenter I. Medical records and standards in clinical documentation. BMJ 2007;334(7602):1045.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Waseem Kazmi, Ushna Khan Durrani, Zara Rathod, Aya Abdelhamid Elshalakany
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.
