Use of a proforma to improve documentation of the post-take ward round and encourage initiation of the comprehensive geriatric assessment in the care of the older people's service

Abstract

Aims/Background The post-take ward round is often the first time that a senior clinician reviews a patient on the acute medical take. Despite this, there is no official guidance regarding structure or documentation of the post-take ward round. The aim of this quality improve project was to develop a ward round proforma specifically tailored to the care of the older people's service to improve quality of documentation and to encourage initiation of the comprehensive geriatric assessment. Methods An initial audit was carried out assessing the documentation of key information and the initiation of the comprehensive geriatric assessment during the post-take ward round. A proforma was subsequently designed and implemented with the aims of improving the quality of documentation and increasing the number of patients for whom the comprehensive geriatric assessment was started. A repeat audit was conducted to assess the effectiveness of the proforma. Results The results demonstrated an improvement in documentation of all key information criteria and an increase in the initiation of the comprehensive geriatric assessment. Conclusions Use of a specifically tailored post-take ward round proforma improves the quality and consistency of documentation and encourages the initiation of the comprehensive geriatric assessment.