Introduction of generic admission and discharge proforma in an obstetric high dependency unit
Abstract Number: 195
Abstract Type: Original Research
Introduction: Inconsistent and poorly structured content in admission and discharge notes can lead to adverse clinical incidents(1). Structured medical records improve health care professional performance, patient outcome and quality of information available for audit and research(2). A structured obstetric specific admission and discharge proforma was introduced to our obstetric high dependency unit (HDU) with the aim of improving patient safety. The admission sheet documents basic demographics, diagnosis, mode of delivery and specific monitoring requirements. The discharge section includes a tick -box systems review, investigation summary and ongoing treatment plan. We audited the impact of the proforma on the adequacy of information documented in HDU notes.
Methods: Case notes of mothers admitted to HDU prior to proforma introduction were retrospectively reviewed for recording of information requested on the new standardised medical record. A program of education emphasising practical use and importance of completion accompanied the introduction of the proforma. A prosepctive case note review of mothers was then completed using solely the
admission and discharge proforma for information collection.
Results: 20 case notes were reviewed prior to introduction and 10 case notes after. The results are
summarised in the table below:
Discussion: Prior to the introduction of the proforma, documentation of the basic information relating to the admission and safe discharge of obstetric HDU patients was unsatisfactory. Documentation of specific monitoring requirements was particularly poor and discharge
information was universally inadequate. The proforma successfully improved quantity and standardised the structure of information collected. Future audit should evaluate the proforma's effect on patient safety by assessing the impact on clinical incidents and effectiveness of
communication between health care professionals.
1. The Audit Commission, PbR Data Assurance Framework 2007/2008:
Findings from the first year of the national coding audit pprogramme.
2008, The Audit Commission: London
2. Mann R, Williams J. Standards in medical record keeping. Clinical
Medicine 2003; 3: 329-332