Improvement In Clinical Recording Keeping Foll...

0 votes
Improvement In Clinical Recording Keeping Following The Introduction Of An Admission Clerking Proforma For Acute General Surgical Patients
Author: Shradha Gupta, Kumaran Ratnasingham, Chi Tamura, Ravindran Karthigan, Veena Bhargava, Nicholas West
Publisher: Derivative Works
6 pages
One time payment: €0.00
Required subscription: Free
Type of publication: Article
ISBN/ISSN: 1179-2760
DOI: 10.2147/CA.S41230
Follow this publisher

Share this publication:


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.

About the publisher:

We are a publishing house devoted to reuse CC-BY licensed published materials.


Using CC-BY licenses:


  • Adapt — remix, transform, and build upon the material
  • for any purpose, even commercially.
  • The licensor cannot revoke these freedoms as long as you follow the license terms.


  • No additional restrictions — You may not apply legal terms or technological measures that legally restrict others
    from doing anything the license permits.


  • You do not have to comply with the license for elements of the material in the public domain or where your use is permitted by an applicable exception or limitation.
  • No warranties are given. The license may not give you all of the permissions necessary for your intended use. For example, other rights such as publicity, privacy, or moral rights may limit how you use the material.

Select a payment method