Background:

There could be important failures in clinical data and plan records that potentially influence the surgical care process.

Objective:

To complete a quality of care improvement cycle on the surgical care process in the General Surgery ward rounds. Structured quality criteria were measured, in order to identify major deficiencies, to implement improvement measures and to reassess the quality of surgical care process. Furthermore, we’ll value the viability the implementation of a structured registration system and nutritional assessment method.

Method:

Comparative quality study (n = 60) before-after the setting of several improvement measures derived from the analysis of the surgical care process. Evaluated criteria were the information received by the patient, adequate recording of the clinical course and plan of care established by the surgeon in the Electronic Health Record, recording of patient’s weight and size and nutritional assessment. Informative sessions, subjective, objective, assessment, plan notes on the electronic clinical record and a nutritional assessment test were implemented.

Results:

There was a significant improvement in all measured criteria (information, data records and nutritional assessment).

Conclusion:

Simple organizational measures allow a significant improvement in the information process, clinical records and malnutrition risk detection in a surgical ward.

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