Ward Round Note Study/Audit

Professor Hill’s TeamGrand Rounds Presentation18.02.2010

What’s the problem?

• Documentation of ward round decisions and clinical decision making is known to be poor in a number of respects

• There have been a number of legislative changes in Ireland relating to medical note keeping in the recent past

What the audit/study aims to examine?• What are the current

standards and practices relating to basic ward round note writing at Beaumont hospital

• How do current practices stand up against basic medico-legal and best-practice guidelines

WHO Checklist • The Second Global Patient

Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care.

  • The checklist identifies three phases

of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia (“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.

Current Practice (insert photo)

Adhesive Ward Round Note

• Insert Photo (blank vs. filled out)

The next step

• Review of ward round notes in charts on AB Cleary

• Analysis• Focus groups on design• Possible implementation

of adhesive ward round note taking across different teams