Proposed Topic (Most preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Authors (including presenting author) :
YUEN YY(1), CHAU KY,DAISY(1), CHAU KY(1), TANG WS(1), CHAN TN(1), CHIU SY(1), WU YY(1), LEUNG YL, MAY(1), HO FH(1), LUNG FC(1), WONG HY(1)
Affiliation :
(1) Accident and Emergency Department
Introduction :
Conducting a documentation audit for resuscitation category 2 cases in Accident and Emergency department is essential to ensure accurate, timeliness and complete recording of critical patient information. Thus, continuous quality improvement (CQI)should be done so as to check and maintain the high quality of triage decision and well documentation. As incorporating the audit process, APNs were refined their learning attributes by personal growth, career advancement and a sense of accomplishment as well as engage in quality improvement initiatives
Objectives :
Set of clear and objective criteria for evaluating the category 2 patient’s resuscitation record. This may include looking for accuracy and completeness of information such as patient identification, presenting complaints, interventions performed, medications administered, and any communication or handover notes. Review all the category 2 case: document any deficiencies or discrepancies were found during the review process. This could include missing or incomplete information, illegible entries, lack of signatures or timestamps, or deviations from the standard documentation practices After identified the area of improvement, the designated APN would be providing training sessions & feedback to nursing staff so as to reinforce good documentation practices & monitor their effectiveness over regular audits.
Methodology :
All category 2 A&E cases were retrieved by AEIS system and selected into the audit from March 2023 to Dec 2023. A&E records, resuscitation records and relevant documentation were recruited for checking by designated APN in the audit month.
Result & Outcome :
From March to Dec 2023, total of 1,900 patient records were audited. Prescription and administration of antibiotic medication was 100% compliance of by IMPOE or AEMOE. Triage time, end-waiting time & disposal time were 100% compliance capture rate. 5 cases of triage time were more than 15-minute & 99.74% compliance within triage pledge that less than 10 minutes. There was only 1 case defined as under triage category otherwise 99.95% with appropriate triage category. There were 40 cases missed to document the patient’s vital sign within resuscitation process; but 97.89% compliance rate with well documentation. There were 88 cases nurse/doctor missed to sign on document; and 95.37% with compliance well. There were 54 cases missed some documentation such as X-ray finding, patient’s past health, triage assessment or stick drug allergy label etc., on the other hand the well documentation compliance rate was 97.16%.
