Admission Proforma Significantly Improves the Medical Record

Abstract

The authors worked in a busy regional fracture unit, where it was noted that important data was being omitted from medical notes. In an attempt to improve on this, an admission proforma was formulated. This was designed to be easily and quickly completed. Notes were audited on two separate weeks, the first before, and the second after introduction of the proforma. The overall results demonstrate statistically significant improvements in documentation with a proforma, and concur with the limited previous literature in this area.