A Quality Improvement Project Aiming to Improve Filing of Ward Round Entries in the Electronic Patient Record

Introduction 
Entries onto the Electronic Patient Record must be saved under a designated ‘Type’, selected from a dropdown menu including: Progress Note, General Clinical Note, Ward Round Note, and other options. Specialities have specific note types, such as ‘Respiratory Medicine Progress Note’. Saving entries under the correct ‘Type’ enables them to be retrieved easily when filtering for speciality-specific input. This project aimed to quantify the proportion of respiratory ward round entries saved under the correct ‘Type’ and introduce an intervention to improve this aspect of medical record keeping. 

Methods 

A retrospective review of all respiratory ward round entries for patients on the Acute Respiratory Care Unit at a District General Hospital in the East of England was conducted over 5 days. Following implementation of a digital poster, highlighting the need and benefit to electronically file notes correctly, a second retrospective review was conducted on the same ward over a further 5 days. 

Results 
67 ward round entries were reviewed during the initial 5 day baseline period. Just 7.5% (n=5) entries were saved under the correct ‘Type’, ‘Respiratory Medicine Progress Note’. Other note types included: Ward Round Note (n=18), Progress Note (n=43), General Clinical Note (n=1).  
Following implementation of the digital poster, a further 67 ward entries were reviewed over a 5 day period on the same ward. Use of the correct note ‘Type’ increased to 80.6% (n=54). The remaining entries were saved under: Progress Note (n=6), General Clinical Note (n=7).  

Conclusion

Implementation of a digital poster increased the use of ‘Respiratory Medicine Progress Note’ from 7.5% to 80.6%. For local departments, future interventions may include in-cooperating similar guidance in induction information for new doctors. Hospitals may wish to increase awareness of the method and benefits of saving notes correctly on Electronic Patient Records.