Improving the Documentation Quality of Pediatric Ward Rounds
Improving the Documentation Quality of Pediatric Ward Rounds
From discussion about the quality of our note keeping, an understanding of what is important to record both clinically and legally, and the guidance on documentation of care provided by the Royal College of Physicians, we agreed that there are nine elements of care that should be recorded in the notes: problem (includes presenting complaint and background complaint); vital signs; investigations; fluids; drugs; patient/parental concerns; nursing concerns; examination; plan. To help everyone remember these, the clinical director developed the mnemonic devise (acrostic) 'Please Verify Information For Doctors, Please Note Every Plan' (Table 1).
The acrostic was formally presented to all the consultants in the department (November 2010; by the clinical director), who agreed to support its use as a strategy to improve the completion of documentation. The acrostic was then introduced at a teaching session for junior doctors. In addition, a laminated copy was attached to all ward round trolleys, with copies placed on the doctors' office notice board also. The acrostic was also incorporated into the mandatory induction training programme for all new doctors to the department. A key element in the success of the introduction of the acrostic was gaining the support of all consultant paediatricians very early in the process. This ensured the junior doctors received a consistent message from all the consultants.
The evaluation was conducted in three phases. The timeline is shown in Box 2. In the first phase of the study, 100 case notes of all children admitted with acute medical problems to the paediatric ward during the study period were audited; 50 before the introduction of the acrostic (June–September 2010) and 50 after (June–September 2011). The notes were selected consecutively from a list, generated by the coding department, of all patients admitted under the single consultant (JCA) in the selected time frame. These notes were selected under the same consultant to try to remove practitioner variability in ward round conduct. Case notes were excluded if the patient had been an elective admission for a day case procedure. The notes were reviewed by two paediatric specialist trainees (ALN and CH) against a data-collection pro forma for adequacy of completion (see online supplementary appendix 1 http://pmj.bmj.com/content/91/1071/22/suppl/DC1 for post-take ward round data-collection pro forma). An individual outcome was measured by the presence or absence of a comment under each heading. If the handwriting was illegible (as judged by the person collecting the data), it was categorised as no record for that heading. 'Investigation' as an outcome was only studied if the child had any investigations performed during that admission. To ensure the robustness of the data for the investigation section, if there was no comment made in the notes, the electronic systems for investigations (this includes blood, radiology and microbiology) were checked to see if any investigations had been carried out.
The second phase was undertaken in 2013 to assess if the initial results were sustained and involved the review of 100 consecutive case notes of children admitted under any consultant paediatrician between June and July 2013. The same data-collection pro forma was used, and the notes were reviewed by a foundation year 1 doctor (CR).
In the final phase of the study (April 2014), 20 paediatric junior doctors completed a survey on their attitude to the use of the acrostic (see online supplementary appendix 2 http://pmj.bmj.com/content/91/1071/22/suppl/DC1 for post-take ward round documentation questionnaire). The focus of the survey was to assess the ease of use of the acrostic as a tool in improving documentation of the post-take ward round and subsequent review of management plans.
We compared the completion of documentation of essential aspects of the post-take ward round before and after introduction of the acrostic. This was done using Minitab 16 statistical package. The null hypothesis that there is no difference in the completion of documentation before and after intervention was tested against the hypothesis that the completion of documentation improved after the intervention. Significance values were calculated by χ test and Fisher exact test, with p<0.05 considered significant.
The introduction of the acrostic led to improvement in the documentation of key aspects of the ward round. In the first phase of the study, there was significant improvement in the documentation of problem (84% vs 94%), investigations (26% vs 72%), fluids (16% vs 74%), drugs (26% vs 76%), patient/parental concerns (16% vs 72%) and nursing concerns (4% vs 48%). There was no significant change in documentation of vital signs (82% vs 92%), examination (96% vs 94%) and plan (96% vs 96%), although these variables all had high documentary compliance before the introduction of the acrostic. Having a standardised format for post-take ward round documentation ensures that observation charts, fluid charts and drug charts are routinely scrutinised on the ward round. This provides the opportunity for any trends in observation charts and any errors or omissions in the drug or fluid charts to be identified and rectified immediately.
The analysis of the second phase showed that the improvement in documentation was sustained in the 2 years since the introduction of the acrostic with further significant improvement in documentation of vital signs (100%), fluids (90%), patient/carer concerns (86%) and examination findings (100%). The results of phase 1 and phase 2 of the study are summarised in Table 2.
A large majority (95% (19/20)) of the junior doctors surveyed agreed/strongly agreed that use of the mnemonic device provided them with an easy format to document essential aspects of the ward round, while 90% (18/20) agreed/strongly agreed that use of the mnemonic device helped reduce time taken to retrieve information from patients' notes when reviewing at a later time. Furthermore, 95% (19/20) agreed/strongly agreed that use of the acrostic provided them with a structured format to present information during ward rounds and to undertake ward rounds themselves. This consistency of approach to ward rounds is very important in a department with a large turnover of junior doctors working various shifts (see Box 3 for advantages of using mnemonic devises to improve care in healthcare settings).
Since introducing this acrostic as a template for documenting post-take ward rounds, it is clear that our patient notes now reflect much more clearly the input of patients and their parents and carers and the involvement of the whole multiprofessional team. These contemporaneously documented discussions may also become an important source of evidence in the case of an incident or complaint. The inclusion of the acrostic in the mandatory induction programme for all new doctors working in the department has helped ensure that the improvement in completion of documentation has been sustained.
The study has confirmed the effectiveness of the acrostic (Please Verify Information For Doctors, Please Note Every Plan) in improving the quality of documentation of a paediatric post-take ward round. Patient notes are now much more informative, and include clear documentation of the views of children, their parents and carers and the involvement of the multiprofessional team. This approach to documentation of the post-take ward rounds has been sustained for 4 years and is an established part of our practice. We plan to re-audit case notes at intervals to ensure the improvement continues. We recommend that the acrostic is widely adopted by other paediatric organisations.
Strategy for Change
Development of the Acrostic
From discussion about the quality of our note keeping, an understanding of what is important to record both clinically and legally, and the guidance on documentation of care provided by the Royal College of Physicians, we agreed that there are nine elements of care that should be recorded in the notes: problem (includes presenting complaint and background complaint); vital signs; investigations; fluids; drugs; patient/parental concerns; nursing concerns; examination; plan. To help everyone remember these, the clinical director developed the mnemonic devise (acrostic) 'Please Verify Information For Doctors, Please Note Every Plan' (Table 1).
Introducing the Acrostic
The acrostic was formally presented to all the consultants in the department (November 2010; by the clinical director), who agreed to support its use as a strategy to improve the completion of documentation. The acrostic was then introduced at a teaching session for junior doctors. In addition, a laminated copy was attached to all ward round trolleys, with copies placed on the doctors' office notice board also. The acrostic was also incorporated into the mandatory induction training programme for all new doctors to the department. A key element in the success of the introduction of the acrostic was gaining the support of all consultant paediatricians very early in the process. This ensured the junior doctors received a consistent message from all the consultants.
Evaluation of Impact of Introduction of the Acrostic
The evaluation was conducted in three phases. The timeline is shown in Box 2. In the first phase of the study, 100 case notes of all children admitted with acute medical problems to the paediatric ward during the study period were audited; 50 before the introduction of the acrostic (June–September 2010) and 50 after (June–September 2011). The notes were selected consecutively from a list, generated by the coding department, of all patients admitted under the single consultant (JCA) in the selected time frame. These notes were selected under the same consultant to try to remove practitioner variability in ward round conduct. Case notes were excluded if the patient had been an elective admission for a day case procedure. The notes were reviewed by two paediatric specialist trainees (ALN and CH) against a data-collection pro forma for adequacy of completion (see online supplementary appendix 1 http://pmj.bmj.com/content/91/1071/22/suppl/DC1 for post-take ward round data-collection pro forma). An individual outcome was measured by the presence or absence of a comment under each heading. If the handwriting was illegible (as judged by the person collecting the data), it was categorised as no record for that heading. 'Investigation' as an outcome was only studied if the child had any investigations performed during that admission. To ensure the robustness of the data for the investigation section, if there was no comment made in the notes, the electronic systems for investigations (this includes blood, radiology and microbiology) were checked to see if any investigations had been carried out.
The second phase was undertaken in 2013 to assess if the initial results were sustained and involved the review of 100 consecutive case notes of children admitted under any consultant paediatrician between June and July 2013. The same data-collection pro forma was used, and the notes were reviewed by a foundation year 1 doctor (CR).
Assessing Doctors' Attitudes to use of the Acrostic
In the final phase of the study (April 2014), 20 paediatric junior doctors completed a survey on their attitude to the use of the acrostic (see online supplementary appendix 2 http://pmj.bmj.com/content/91/1071/22/suppl/DC1 for post-take ward round documentation questionnaire). The focus of the survey was to assess the ease of use of the acrostic as a tool in improving documentation of the post-take ward round and subsequent review of management plans.
Data Analysis
We compared the completion of documentation of essential aspects of the post-take ward round before and after introduction of the acrostic. This was done using Minitab 16 statistical package. The null hypothesis that there is no difference in the completion of documentation before and after intervention was tested against the hypothesis that the completion of documentation improved after the intervention. Significance values were calculated by χ test and Fisher exact test, with p<0.05 considered significant.
Effects of Change
The introduction of the acrostic led to improvement in the documentation of key aspects of the ward round. In the first phase of the study, there was significant improvement in the documentation of problem (84% vs 94%), investigations (26% vs 72%), fluids (16% vs 74%), drugs (26% vs 76%), patient/parental concerns (16% vs 72%) and nursing concerns (4% vs 48%). There was no significant change in documentation of vital signs (82% vs 92%), examination (96% vs 94%) and plan (96% vs 96%), although these variables all had high documentary compliance before the introduction of the acrostic. Having a standardised format for post-take ward round documentation ensures that observation charts, fluid charts and drug charts are routinely scrutinised on the ward round. This provides the opportunity for any trends in observation charts and any errors or omissions in the drug or fluid charts to be identified and rectified immediately.
The analysis of the second phase showed that the improvement in documentation was sustained in the 2 years since the introduction of the acrostic with further significant improvement in documentation of vital signs (100%), fluids (90%), patient/carer concerns (86%) and examination findings (100%). The results of phase 1 and phase 2 of the study are summarised in Table 2.
A large majority (95% (19/20)) of the junior doctors surveyed agreed/strongly agreed that use of the mnemonic device provided them with an easy format to document essential aspects of the ward round, while 90% (18/20) agreed/strongly agreed that use of the mnemonic device helped reduce time taken to retrieve information from patients' notes when reviewing at a later time. Furthermore, 95% (19/20) agreed/strongly agreed that use of the acrostic provided them with a structured format to present information during ward rounds and to undertake ward rounds themselves. This consistency of approach to ward rounds is very important in a department with a large turnover of junior doctors working various shifts (see Box 3 for advantages of using mnemonic devises to improve care in healthcare settings).
Lessons Learned
Since introducing this acrostic as a template for documenting post-take ward rounds, it is clear that our patient notes now reflect much more clearly the input of patients and their parents and carers and the involvement of the whole multiprofessional team. These contemporaneously documented discussions may also become an important source of evidence in the case of an incident or complaint. The inclusion of the acrostic in the mandatory induction programme for all new doctors working in the department has helped ensure that the improvement in completion of documentation has been sustained.
Next Steps
The study has confirmed the effectiveness of the acrostic (Please Verify Information For Doctors, Please Note Every Plan) in improving the quality of documentation of a paediatric post-take ward round. Patient notes are now much more informative, and include clear documentation of the views of children, their parents and carers and the involvement of the multiprofessional team. This approach to documentation of the post-take ward rounds has been sustained for 4 years and is an established part of our practice. We plan to re-audit case notes at intervals to ensure the improvement continues. We recommend that the acrostic is widely adopted by other paediatric organisations.
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