Material and Methods:
We carried out a retrospective audit of consecutive patients admitted to the surgical take. Accuracy of documentation pertaining to areas identified in national standards was recorded. After an initial audit, a surgical clerking proforma was introduced to improve documentation.

Result:
44 patient notes were reviewed in the initial audit (Group 1) and 41 patients after introduction of the proforma (Group 2). Significant improvements were seen in documentation of patient identifier details - documented correctly in 27% of Group 1, which improved to 66% in Group 2. Significant improvements were also seen in time and date of clerking (50% to 70%), medication history (43% to 93%), family history (2% to 29%), physical examination and blood results (14% to 61%) - all p-value < 0.05.

Conclusion:
A clerking proforma can significantly improve documentation in a patient’s admission notes facilitating better patient care and improving adherence to legal requirements.