BACKGROUND
Accurate and comprehensive documentation during surgical ward rounds is essential for patient safety, care continuity, and medicolegal purposes. Traditional note-taking, often delegated to junior staff during fast-paced orthopedic rounds, risks omission of vital details. Standardized proformas based on problem-oriented frameworks, such as SOAP (Subjective, Objective, Assessment, Plan), may enhance documentation quality.
METHODS
This hospital-based quality improvement project was conducted in the Department of Orthopedics at Patan Hospital, Nepal, over six weeks. A SOAP-based standardized proforma was developed with faculty input and implemented for morning ward rounds in patients undergoing operative procedures. Documentation quality was assessed prospectively by comparing 50 ward round notes before and after proforma introduction, analyzing completion rates for key documentation elements.
RESULTS
After implementation, documentation completeness improved across all measured domains. Recording of the patient’s name improved from 12% to 96%, plan from 44% to 90%, diet status from 20% to 88%, and discharge planning from 62% to 100%. Subjective and objective elements also showed improvement, and overall completeness increased from 60.8% to 96.7%. Feedback from medical and nursing staff indicated enhanced clarity and satisfaction with the documentation.
CONCLUSION
A standardized SOAP-based ward round proforma significantly improved documentation in orthopedic post-operative ward rounds. This approach enhances communication, supports safe patient care, and may reduce medicolegal risk. Broader adoption of such structured templates is recommended to ensure essential information is consistently recorded.
KEYWORDS
documentation; orthopedic procedures; patient safety; quality improvement; ward rounds