Improving Documentation in Neck of Femur Fracture Admissions: A Quality Improvement Project redesigning a clerking proforma

Background:

Neck of Femur fractures (NoFs) are associated with significant morbidity, mortality and prolonged hospital admission. These make up a significant portion of the Trauma and Orthopaedic admissions at Weston General Hospital. Optimal management requires multidisciplinary assessment and timely optimisation to meet the national targets for management of fractures. A review of the clerking proforma prior to this audit found variability in the documentation quality and completeness.

Aim:

To assess baseline documentation quality in NoF admissions and evaluate the impact of a redesigned clerking proforma on completeness.

Methods:

A quality improvement project involving audit of the NoF proforma and its documentation, followed by editing of the clerking proforma to allow for more space, additional details and more prompts for information. Twenty pre-intervention proforma were compared with twenty-eight following redesign. Documentation quality was assessed with a predefined checklist covering: a clear history, social history, family conversation, frailty and delirium assessment, investigations, peri-operative planning, senior review and early post-operative care.

Results:

The redesigned proforma appeared to improve completeness and documentation. Improved completion was more apparent in the frailty and delirium assessment, peri-operative planning, VTE documentation, results recording and post-operative reviews. Structured prompts and tick-box sections improved recording of patient details for the multidisciplinary team regarding baseline function, cognition and social circumstances. However persistent difficulties remained in senior review documentation clarity, next of kin details and medication accuracy. Limitations include the small sample size, and variation between patient complexity and clinicians.

Conclusion:

Redesign of the NoF proforma improved documentation quality, which may support safer, more patient focused care for frail orthopaedic patients. Improving recording of frailty, cognition and peri-operative planning is likely to support multidisciplinary decision making and post-operative recovery. Future work should involve both staff education and re-audit, with evaluation of patient outcomes.