QUALITY IMPROVEMENT PROJECT TO IMPROVE ACUTE MEDICAL UNIT'S WARD ROUND ENTRIES AS PER GENERIC MEDICAL RECORD KEEPING STANDARDS SET BY ROYAL COLLEGE OF PHYSICIANS AT A DISTRICT GENERAL HOSPITAL

Background and reason for the project: It was brought to attention by the ward matron of the Hospital’s AMU that a lot of junior doctors and physician associates were not making ward round entries as per the standards, causing patient safety issues. For instance, not putting patient’s full name and ID on all the pages of notes or not documenting the time entry etc. According to RCP approved ‘Generic Medical Record Keeping Standards’; every page in the medical record keeping should include patient’s name, identification number and location in the hospital. Every entry in the medical records should be dated, timed and signed by the person making the entry along with their name and designation. Every entry in medical record keeping should identify the most senior healthcare professional present [who is responsible for decision making] at the time entry is made. In addition to that, the consultant responsible for patient’s care should also be mentioned with each entry.

This project will looked at if these guidelines are being followed in our AMU ward rounds.