Improving documentation within the acute stroke unit

"The results of this project have shown that by introducing a stroke specific clerking document, the quality of information recorded has significantly improved."

Improving documentation within the acute stroke unit: Introducing a stroke specific clerking proforma
S Patel
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u208852.w3847

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Simple interventions can greatly improve clinical documentation

"In conclusion, simple, cost effective measures in streamlining medical notes, improves the quality of documentation, facilitates the filing and ultimately improves patient care."

Simple interventions can greatly improve clinical documentation: a quality improvement project of record keeping on the surgical wards at a district general hospital
P Glen, N Earl, F Gooding, E Lucas, N Sangha, S Ramcharitar
BMJ Quality Improvement 2015;4: doi:10.1136/bmjquality.u208191.w3260

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Improving the recording of surgical drain output

"We have demonstrated that the introduction of a simple and well-designed drain chart can significantly improve the documentation of drain output, thereby improving patient safety and discharge efficiency."

Improving the recording of surgical drain output
Nicholas Lyons, Paul Heron, Rob Bethune
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u209264.w3964

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5 basic hospital inefficiencies and their quick fixes

"Although many of the issues that lead to inefficiency may be complex, there are still some quick fixes that can add up to huge savings in both staff time and money. Here are some of the most common hospital inefficiencies and some simple strategies that can help to correct them"

5 basic hospital inefficiencies and their quick fixes
J Henry
Healthcare Dive
February 2015

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Evaluating the Quality of Medical Documentation at a University Teaching Hospital

"Following the introduction of Electronic Patient Records (EPR) to NHS trusts and the freedom of information available to patients, the need for transparent and clear documentation is even more important. The aim of the study was therefore to evaluate the quality of medical documentation in patients’ notes across the different specialties based at the hospital."

Evaluating the Quality of Medical Documentation at a University Teaching Hospital
E Ridyard, E Street
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u208052.w3253

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Improving the quality of documentation of referrals to neurosurgery

"The aim of this project was to identify the current level of documentation and improve this through departmental education and implementation of a referral proforma. National guidelines and a literature review were used to formulate the gold standard for high quality documentation."

Giving ourselves a head start: improving the quality of documentation of referrals to neurosurgery
M Storey, S Webster
BMJ Quality Improvement Reports 2015;4: doi:10.1136/bmjquality.u203531.w2516

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Intravenous fluid prescribing: Improving prescribing practices

"as a result of improved documentation and consideration given to fluid prescriptions, we were able to increase the percentage of maintenance IV fluid prescriptions that conformed to NICE guidelines."

Intravenous fluid prescribing: Improving prescribing practices and documentation in line with NICE CG174 guidance
BMJ Quality Improvement Reports 2014;3: doi:10.1136/bmjquality.u205899.w2409

LT Sansom, L Duggleby

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Ward round documentation in a major trauma centre: can we improve patient safety?

"We show that our new system of note keeping for use during ward rounds in a major trauma centre improves both the quality and consistency of ward round entries. It consolidates each member of the team’s knowledge about each patient, and contributes to effective handover. "

Ward round documentation in a major trauma centre: can we improve patient safety?
G Green, A Aframian, J Bernard
BMJ Quality Improvement Reports 2014;3: doi:10.1136/bmjquality.u206189.w2537

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