Introduction

Accurate and complete documentation in medical records has been shown to benefit both patient care and clinician performance [1, 2]. Of particular importance is the initial admission note, which is frequently used as a reference point for the patient’s history during their hospital stay. An adequate admission note is particularly critical for communicating key information when the patient is most unwell [2]. The Health Service Executive (HSE) states that “care of the service user may be affected if complete admission information is not available to aid decisions around treatment” [3]. This is of particular importance in a surgical context where there is a narrow margin for error [2]. Inadequate admission documentation has been linked with poorer patient care, with a higher rate of adverse events reported in patients where documentation was deemed lacking [4]. Poor-quality documentation may also have medicolegal consequences and act as a barrier for hospital coders, impacting an institution’s ability to accurately capture the volume and complexity of care provided [2, 3].

The HSE Standards and Recommended Practices for Healthcare Records Management details what a hospital admission note should contain [3]. This includes the presenting complaint, past medical history, medication list, physical examination findings, results of investigations and treatment plan. Despite such clear recommendations, it has been shown that the standard of admission documentation is unacceptable in up to 10% of hospital admissions, with one or more of these criteria not recorded [5, 6]. Current standard practice for general surgical admissions in most Irish hospitals is by handwriting notes on lined paper. With such critical information omitted on such a frequent basis, the need to standardise the admission documentation process is evident. Furthermore, it has been demonstrated that healthcare professionals prefer to use structured admission proformas compared to handwritten notes [7].

Structured admission proformas have been used in the hospital setting to improve the quality and completeness of admission documentation, but there are few studies that directly compare the efficacy of freehand admission notes with a structured admission proforma, particularly in the context of emergency general surgery. We set out to design a standardised, structured admission proforma for use with all emergency general surgery patients admitted through the emergency department in a busy model 3 hospital. With this, we aimed to assess the quality and completeness of surgical admission notes using such a proforma compared to the traditional freehand method.

Methods

The surgical admission proforma was designed based on the standards and recommendations set by the HSE [4]. This was reviewed and approved by all surgical consultants in the department and the hospital documentation committee. Prior to the implementation of this, a retrospective audit of all emergency general surgery admission notes over a 4-week period was performed by four independent data collectors. The data collectors were all surgical non-consultant hospital doctors (NCHDs) working in the department. Each admission note was independently reviewed by two data collectors, with measures taken to ensure that NCHDs did not review their own admission notes. If there was any dispute between the two independent data collectors regarding the findings from the review of an admission note, this was resolved by a further review performed by a senior author.

After implementation, on-call teams were requested to use the proforma instead of freehand documentation. To allow for staff to familiarise themselves with the new system, a 2-week introduction period was put in place, with frequent reminders given to on call staff to ensure awareness of the new proforma. Following this, the audit of admission notes was repeated. On-call staff were not made aware that their documentation would be audited either before or after implementation of the proforma. Documentation both before and after implementation of the proforma was assessed based on the presence or absence of 19 criteria outlined by the HSE Standards and Recommended Practices for Healthcare Records Management [3] (Table 1). These criteria were recorded as being either present or absent by the data collectors.

Table 1 Criteria for documentation
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Admission notes completed by the authors were excluded from the study. Data analysis was performed using Strata 14 (StrataCorp, TX), with the difference in documentation before and after implementation compared using Fisher’s exact test. A p value of less than 0.05 deemed statistically significant. As this was an audit, ethics committee approval was not required.

Results

Patient notes were assessed both before and after implementation of the surgical admission proforma (n = 251 and n = 273, respectively). Compliance with the new admission proforma was 97%. Documentation was improved in all 19 of the criteria assessed, with statistical significance achieved in 17 of these. Of those outlined in Table 1, the only two criteria to not demonstrate a statistically significant improvement were the presenting complaint and the history of the presenting complaint (see Table 2).

Table 2 Comparison of documentation before and after proforma introduction
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Key criteria in the initial assessment of the patient including the past medical and surgical history, medication list, allergy status, social history, family history, physical examination findings, vital signs, blood results and the management plan all showed significant improvement after implementation of the admission proforma.

A safety checklist was included as part of the design of the proforma, which aimed to ensure important steps regarding patient management and communication with relevant staff were performed. A vast majority (96%) of the admission notes reviewed were completed by senior house officers, the most junior doctor on call for the surgical team in the emergency department. However, the proforma safety checklist prompts the admitting doctor to document if the patient has been discussed with their senior. Following implementation of the proforma, 87% of admission notes referenced discussion of the patient with a senior colleague, compared to 53% in freehand notes. The proforma also prompts the admitting doctor to communicate the management plan with nursing staff. Of admissions completed using the proforma, 74% showed that the plan had been communicated to nurses, while none of the freehand admission notes did. With regard to female patients, the result of the urinary pregnancy test was documented in 71% of proforma admissions, compared to 26% of freehand admissions. The fasting status was stated in 87% of proforma admissions compared to 79% of freehand admissions. An improvement in the documentation of whether DVT prophylaxis was required was also seen in the proforma admissions (91% compared to 49%).

Discussion

Complete and coherent medical documentation is essential to ensure patient safety and efficiency of care during their hospital stay. The admission note is particularly invaluable, being frequently referred to during the patient’s admission, especially when most are unwell and during handover of care. Despite the critical importance of this, significant failings in ensuring the completion of an adequate admission note have been recognised [5, 8]. We have demonstrated the impact a structured admission proforma can have in addressing these deficiencies in documentation compared to freehand admission notes. Other studies have shown an improvement in admission documentation by use of structured proforma, but few demonstrate this in the context of emergency general surgery [2, 9, 10]. It has been shown that doctors who record more detailed medical notes are more likely to detect adverse events [11]. Our proforma provides a framework to ensure that high-quality admission documentation can consistently be produced by on-call staff.

As well as providing improved patient safety, the proforma also provides many benefits to medical staff. A survey of over 1000 doctors showed that clinicians overwhelmingly prefer the use of an admission proforma compared to freehand notes [12]. A clearly structured document can help streamline the admission process, and acts as a useful reference tool when a doctor is called to see a patient unfamiliar to them. It has been demonstrated that structured proformas improve access to relevant clinical information and reduce delays in the clinical setting [9]. It does so by making important information easier to access by consistency of subheadings appearing in a pre-determined order [2, 13]. It is for this reason that structured proformas have also been shown to improve efficiency on post-take ward rounds [2].

The structured proforma may also be useful in a medicolegal context. A significant proportion of litigation relies heavily on documentation in the medical records to determine if appropriate actions were taken [5]. The proforma acts to highlight key steps such as documentation of appropriate investigations, a clear management plan and discussion with a senior colleague. The proforma may also be a valuable tool for doctors that wish to partake in audit and research, with the consistent structure making data collection easier and ensuring that essential information required for projects is not omitted. Importantly, all four data collectors found the data collection process significantly easier with the proforma compared to freehand notes. With regard to clinical coding, the proforma acts to more consistently provide relevant information required to accurately capture the volume and complexity of work performed by a hospital [3].

The proforma serves to act as a reminder of best practice to all doctors that use it. Other disciplines, such as respiratory medicine or obstetrics, have demonstrated that pre-printed forms have a positive impact on doctors’ performance [14, 15]. Following implementation of the proforma in our centre, documentation of important details such as background history, medication lists, allergy status, vital signs, blood results and a clear management plan significantly improved. The proforma also ensures essential safety factors are considered, such as discussing the case with a senior colleague, the requirement for antibiotics, the requirement for venous thromboembolism prophylaxis, checking pregnancy test results, if the patient is required to fast or if further investigations are required. The structured document reminds the on-call doctor to consider these factors which could be easily overlooked, particularly in the context of a busy call shift with multiple admissions. The proforma also acts to improve communication, prompting the admitting doctor to clearly communicate the management plan to nursing staff.

Our study is not without limitations. While the 19-point criteria for assessing the quality of admission notes was modelled on HSE recommendations, application of this could be vulnerable to subjectivity. However, efforts were made to overcome this by having each note reviewed by two independent data collectors, with any discordancy in findings resolved by senior author input. Minimal inter-rater variability was noted, with only 9 admission notes requiring senior review. We did not demonstrate if patient outcomes improved following implementation of our proforma. However, it has been demonstrated before that poor-quality admission documentation is associated with negative patient outcomes [2]. It is also important to highlight that, while all aspects of documentation did improve with the proforma, some elements of documentation remained at a poor standard. Factors such as smoking history, alcohol intake and activities of daily living were frequently omitted, and this may reflect an attitude that these details lack relevance as part of a surgical admission, despite being essential factors to consider with regard to any hospital admission, particularly in relation to post-operative recovery. Structured proformas have faced some criticism in that they act to limit free expression and turn medicine into a ‘box-ticking exercise’ in a context where physicians should be encouraged to be dynamic and innovative [16]. Despite this, it has been shown that their use is preferred by most clinicians, and the benefits towards safety and efficiency for both the patient and doctor that have been demonstrated show a clear advantage towards their use [7].

In conclusion, our study demonstrates that a structured surgical admission proforma significantly improves the quality and completeness of admission documentation. This acts to ensure greater patient safety and greater efficiency of care. This is likely to have a positive impact on patient outcomes, doctors’ performance, hospital efficiency, communication and audit quality control, thus providing multiple clear benefits in comparison to freehand admission notes.