Value of an orthopaedic admission proforma.

Abstract

Admission notes are an important aspect of clinical practice and a vital means of communication among healthcare professionals. Incomplete or poor clinical documentation on admission can lead to delayed surgery. A retrospective analysis of 20 consecutive admission notes to our department was compared against the Royal College of Surgeons standards (GSP 2014). A new admission proforma was designed, and after the introductory period, two further retrospective cycles were performed. In total, 60 admission notes were analysed. Following the introduction of the proforma, there was an overall improvement in the documentation of the quality and quantity of notes studied. Our study demonstrated that a well-structured admission protocol can improve the overall quality of admission notes.