Title : Improving documentation of post-operative review via a proforma in trauma and orthopaedics: A 2-cycle audit
Abstract:
Background:The post-operative review is important in orthopaedics patients to assess neurovascular status for early detection of neurovascular deficits. It is also an opportunity to ensure that low-molecular weight heparin (LMWH) and antibiotics are prescribed, if indicated. In our local health board, a proforma is available to guide junior doctors towards clear and accurate documentation of the post-operative review.
Aim: To improve the rate and quality of documentation of post-operative review in orthopaedics patients using a proforma.
Methods: In the first cycle, all patients admitted under trauma and orthopaedics who had surgery in January 2025 were included. Electronic patient records were reviewed. Completion of the post-operative review proforma, which includes a neurovascular status examination and checking if LMWH and antibiotics are prescribed, was reviewed. Interventions were implemented in the form of departmental teaching and an educational poster circulated via email and within the orthopaedics wards. The second cycle was re-audited in May 2025.
Results: In the first cycle, 183 patient notes were reviewed where 160 (87%) post-operative review proformas were completed. The rate of documentation of neurovascular status were: pain level (128, 80%), colour (114, 71%), pulse (104, 65%), sensation (135, 84%), power 135 (84%). DVT prophylaxis was indicated in 120 (75%) of patients where 116 (97%) were prescribed LMWH. In the second cycle, after implementation of the interventions, 148 notes were reviewed where 145 (98%) proformas were completed. Documentation of neurovascular status also improved significantly: pain level (144, 99%), colour (140, 97%), pulse (141, 97%), sensation (142, 98%), power (141, 97%). DVT prophylaxis was indicated in 120 patients where all patients (100%) had LMWH prescribed. In both cycles, 100% of patients received prophylactic antibiotics when indicated.
Conclusion: The post-operative review is important to ensure early detection of neurovascular deficits post-intervention and ensure prophylactic LMWH and antibiotics are prescribed appropriately. Several challenges were identified, including high patient turnover, increased workload and omission of patients during handovers. Effective communication between junior doctors is key in ensuring post-operative reviews are done and clearly documented for patient safety and better outcomes.
