AB200. SOH25_AB_299. A prospective audit of current surgical admission documentation in Wexford General Hospital and survey of attitudes to current surgical admission proforma
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AB200. SOH25_AB_299. A prospective audit of current surgical admission documentation in Wexford General Hospital and survey of attitudes to current surgical admission proforma

Jessica Egbulam, Chris Ramkaran, Ellen Boyle, Ivan Ivanovski, Mark Grannell, Sandro Magrini, Suhail Khan

Department of Surgery, Wexford General Hospital, Wexford, Ireland

Background: Comprehensive documentation of patients presenting to the acute surgical team is an essential component of delivering a safe on-call service. We completed a prospective audit of admission documentation with the current surgical admission proforma, introduced over 35 years ago, and surveyed relevant stakeholders on their experience with it.

Methods: An audit of admissions using the current proforma was undertaken over a 2-week period using guidelines from the Health Service Executive (HSE). An anonymised survey of all stakeholders was conducted to investigate experiences with the current proforma.

Results: Fifty admissions were evaluated. Key elements of documentation, past medical history, past surgical history, and current medications were documented in 62%, 65%, and 31%, respectively. Social aspects, living situation, and functional status were documented in 12% and 8%. Patient allergies and overall impression were documented in 30% and 4% of cases. Resuscitation status was not documented in any of the admissions. The survey of surgical non-consultant hospital doctors (NCHDs) had a response rate of 60% (12/20). All respondents felt the current surgical proforma was not fit for the purpose. The most popular aspects for redesign were the expansion of ‘history of presenting complaint’ and the reformatting of the exam section, with 75% of respondents considering it very important.

Conclusions: Current documentation trends for surgical admissions in Wexford General Hospital are not compliant with HSE-mandated standards. All stakeholders involved in clerking acute surgical presentations feel the current surgical proforma is not fit for purpose and support a new, modernized proforma. A new proforma is planned for implementation, with a plan to re-audit to assess impact.

Keywords: Admission proforma; clinical governance; acute surgery; quality improvement; patient safety

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

doi: 10.21037/map-25-ab200
Cite this abstract as: Egbulam J, Ramkaran C, Boyle E, Ivanovski I, Grannell M, Magrini S, Khan S. AB200. SOH25_AB_299. A prospective audit of current surgical admission documentation in Wexford General Hospital and survey of attitudes to current surgical admission proforma. Mesentery Peritoneum 2025;9:AB200.

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