European Journal of Cardiovascular Medicine

Introduction: Ward round documentation provides one of the most important means of communication between healthcare professionals. We aimed to establish if the use of a problem based standardised proforma can improve documentation in acute surgical receiving. Using checklists has been common in high-risk industries such as aviation, space, and maritime sectors. It is routinely being used in health care also. Daily ward rounds play an essential role in patient care. Missing key details in rounds are common. Sometimes, these medical errors can lead to adverse events or mismanagement of patients. A checklist was introduced for daily ward rounds in our newly established institution. This study aims to assess the improvement in the documentation. Materials and methods A checklist for ward rounds was introduced in September 2021 to September 60 random case records for each of the two groups were taken. Group A (without checklist) and Group B (checklist) were compared to see the documentation of patient identification, diagnosis, operative status, fresh complaints, vitals, examination findings, charting treatment, catheter/drains/intravenous access and urinary status/bowel movements: Results 120 case records were included in the study. Comparison of documentation between Group A and Group B showed a significant difference in patient identification (50% vs. 100%), diagnosis (47% vs. 100%), operative status (33% vs. 100%), fresh complaints (76% vs. 100%), vitals (63% vs. 100%), examination findings (43% vs. 100%), charting treatment (73% vs. 100%), catheters/drains/intravenous access (10% vs. 86%), and urinary status/bowel movements (30% vs. 100%). We found that after introducing checklist significantly improvement of communication between healthcare workers, stress reduced and improve the quality of treatment. Conclusion Using checklists for daily ward rounds improves documentation. It reduces the gap in communication and potential errors in patient management. -We found that after introducing checklist significantly improvement of communication between healthcare workers, stress reduced and improve the quality of treatment.