Neelam Rathod, Khemanand Maharaj, Vyomesh Bhatt

Introduction and aims

Initial comprehensive documentation on the assessment of acute OMFS patients during on-call duties is vital for efficient and effective management of patients. Several factors may pose a challenge in this process for those that are carrying out this process of patient management. An audit was undertaken to evaluate and improve the quality of initial assessment documentation for OMFS facial trauma and acute swelling presenting to Broomfield hospital, Essex.

Method

Current practice was assessed by evaluating initial documentation of patients who underwent emergency GA procedures for facial trauma and swelling over a 2-month period. Data was evaluated against recording keeping guidelines set out by the GMC, RCS and defence unions. In response to the findings of the evaluation, a facial trauma and separate swelling pro-forma was implemented for all acute cases, with data being collected prospectively over a 1-month period. A feedback form was also sent to clinical members of the OMFS team to further enhance the documentation process.

Results

With a 100% baseline standard set, initial data collection for trauma showed less than 50% of records had evidence of documentation in areas of clinical history, medical history and clinical assessment. For acute facial swelling assessment, less than 50% of records had appropriate documentation on aspects of social history, clinical assessment, special investigations and management plans. Implementation of a facial trauma pro-forma resulted in improvements in all aspects of documentation, with more than 90% of records in various aspects meeting required standards. Preliminary evaluation of the acute facial swelling pro forma reveals similar findings in all aspects of clinical documentation.

Conclusion

The implementation of a clinical assessment pro-forma has a positive impact on the quality and clarity of medical records. This will ensure appropriate patient management and optimal safety as well as complying with clinical governance requirements.

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