Ward Round Note Study/Audit
Professor Hill’s Team
Grand Rounds Presentation
18.02.2010
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 bestpractice 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