摘要：Background: In 2008, the Royal College of Physicians (RCP) alongside National Health Service Connecting for Health endorsed standards for patient records to improve patient safety by standardizing the information held on patients throughout their stay in hospital. Opinion on accurate recordkeeping, safe handover, and optimal management of acute surgical patients has reached a consensus within general surgical practice since the publication of the Handover Guidance and the Emergency Surgery Standards by the Royal College of Surgeons of England. This audit assesses the improvement in clerking notes following implementation of a proforma for acute surgical admissions. Method: The surgical admission clerking notes of 100 acute patients were audited against standards derived from the Handover Guidance and Emergency Surgery Standards, and RCP Record Keeping Standards. A standardized proforma was constructed and implemented across the unit and 100 patient notes were audited in a second audit cycle. Results: The proforma significantly improved documentation across multiple fields including patient history, patient examination, and investigations ( P < 0.05). Completion of venous thromboembolism risk assessment increased by 62% ( P < 0.001). There was increased documentation of the time taken until senior review of the patient post-admission, which occurred within an average of 323 minutes, an overall improvement of 173 minutes. Conclusion: The use of a surgical clerking proforma on admission has been shown to improve documentation significantly, and standardize the information recorded for patients admitted in an acute general surgical setting. A proforma can also be used as an audit tool to measure against national standards.
