Swetha Pathap
Introduction:
Plastics Trauma Clinic (PTC) provides a daily service dedicated to assessing patients with minor trauma. Definitive treatment is either conservative or sameday surgery. According to GMC Good Medical Practice Standards, patient records should be documented with sufficient detail, which is commonly overlooked in PTC proformas. Adequate documentation is essential for effective handover between colleagues and for reducing the risk of unnecessary medical litigation.
Methods:
A retrospective analysis was performed on 22 components of the PTC proformas for first-time patients, using clinic data from September–October 2024 (Cycle 1) and February–March 2025 (Cycle 2). Cycle 1 data was presented at the monthly Plastic Surgery meeting.
Results:
A total of 67 patients were reviewed in Cycle 1, and 82 in Cycle 2. Overall compliance with documentation improved from 67.6% to 73%. The number of ‘unidentifiable’ clinicians decreased from 13 to 4 proformas. Notable improvements were seen at junior levels, with a 10% increase in compliance at both SHO and Registrar levels. Despite improvements, many proformas still lacked critical information, such as the clinician’s name, grade, and signature (Cycle 2 compliance: 56.8%, 33.3%, and 75.3%, respectively). Marginal improvements were seen in injury-specific components, but gaps persist in basic parameters.
Conclusions:
Although overall documentation compliance improved, there is significant potential for further improvement. Ongoing re-auditing, along with targeted education on the importance of thorough documentation, is essential to enhance patient care and reduce potential risks. Future initiatives will focus on addressing the remaining gaps and ensuring long-term improvements in documentation standards.
Authors
Swetha Prathap
Hull Royal Infirmary, Hull, United Kingdom
Samuel Teklay
Pinderfields hospital, Leeds, United Kingdom
Gillian Rose
Hull Royal Infirmary, Hull, United Kingdom