Ward Round Note Study/Audit Professor Hill’s Team Grand Rounds Presentation

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