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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
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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 best-practice 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.
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
