Presentations 2020: OMFS

433 - Oral and maxillofacial surgery admission pro forma, will it hold value?

A Hussain S Ananth
Presented by: Aarifa Hussain
Cardiff Dental Hospital

Introduction The NHS Quality and Safety programme emphasises how medical records are essential for effective handover of care, particularly in the acute situation of an unwell patient. Incomplete clerking puts patients at unnecessary risk of adverse events. The regular rotation of dental core trainees in OMFS posts poses the need for reinforcement of medical record keeping in order to maintain a high standard of documentation. Surgical teams at the University Health Board Cardiff and Vale have favoured admission booklets over free hand clerking. OMFS does not have a standardised pro forma in place. This Quality Improvement project aims to assess dental core trainee confidence in pre-clerking patients, identify the number of delays to theatre caused by incomplete clerking and compare OMFS free hand records to other specialty admission documents within the University Health board. Methods The number of patients per theatre session where treatment was delayed or cancelled was examined retrospectively from September 3rd 2019 to December 31st 2019 and the number caused by pre-clerking errors was measured. Using the above inclusion criteria, clerking entries were assessed against the Royal College of Surgeons (RCS) 1995 and 2005 guidelines and compared against the standardised pro forma for general surgery, trauma, and ENT. A questionnaire was designed and distributed to dental core trainees to assess confidence with pre-clerking patients. All emergency admissions were excluded. Results The total number of patients whose care was affected by lack of information prior to theatre was negligible at 0.06%. This accounted for unfilled VTE forms and undocumented test results. 75% of DCTs felt they needed senior advice when pre-clerking oncology patients and 100% felt they would benefit from a standardised pro forma. Conclusion An admission booklet has been designed for OMFS to improve information flow between teams. A second cycle of data collection will be carried out.
Consent Statement: There are no details on individual patients reported within the abstract.

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