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Daily ward rounds (WR) represent a fundamental part of the delivery of surgical care. It is an opportunity for the senior members of the team to review all aspects of the patient’s treatment pathway and decide on the most appropriate management plan going forward.
The quality and effectiveness of a WR relies on good documentation. Not only from a medico-legal perspective but also as communication between multidisciplinary teams (MDT). Both in and out of hours, the information written on the WR directly influences decisions made and therefore patient safety. Furthermore, the introduction of the European Working Time Directive has created complex shift-based work patterns, in which the members of the WR are regularly rotating.1 Good documentation is the one constant that maintains effective continuity of care and is the base of good patient care.
The General Medical Council (GMC) of the UK has clear guidance on what is expected to be documented in the doctor–patient interactions.2 Despite this, research continues to find a failure to reach these standards.3–7 In fact in a UK study of 432 surgeon–patient consultations, key information …
Contributors All authors have contributed throughout this project, from data collection, analysis of results and writing of the report.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.