Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Authors (including presenting author) :
Lin OY (1), Cheung KS(2), Chan WK(3), Ng YL(4), Tsang E(5), Wong C(6), Chan TC(1)
Affiliation :
(1) Medicine and Geriatrics, Fung Yiu King Hospital
(2) Dietetics, HKWC
(3) Community care Service, HKWC
(4) Occupational Therapy, HKWC
(5) Medical Social Service, HKWC
(6) Physiotherapy, HKWC
Introduction :
Most residential care homes (RCHEs) in HKWC do not have computer with CMS Citrix available. Moreover, the internet network of many RCHEs is quite unstable. Therefore, when doctors, nurses and allied health colleagues went to RCHE to see patients in the past, they had to handwrite the consultation notes and drug presentation at RCHE. The consultation notes were then kept in RCHE. If these RCHE residents were admitted to hospitals, these medical records would be very difficult to trace during in patient period. Therefore, we have planned for a gradual roll out of electronic documentation in HKW CGAT since 2021. In 1Q 20022, electronic documentation of doctor consultation was fully implemented in HKW CGAT clinic smoothly. Then, HKW CGAT was planning to roll out the electronic nursing and allied health documentation as the next step.
Objectives :
To achieve 100% implementation using electronic progress notes for all doctor, nurse and allied health documentation in HKW CGAT
Methodology :
In 1Q 20022, electronic documentation of doctor consultation was fully implemented in HKW CGAT clinic smoothly. Trial run of nursing electronic documentation covering 4 RCHEs was started in 1Q 2021. Nursing notes template for CGAT nurse clinic and EOL clinic were developed. iPad mini with SIM card, keyboard were purchased. Full implementation was performed to all RCHEs in 3Q2023. Workgroup for allied health electronic documentation was formed in Apr 2023. Pilot run was started in 2Q 2023 and full implementation also carried out in 3Q2023.
Result & Outcome :
Electronic Documentation has been fully implemented in HKW CGAT clinic smoothly in 3Q 2023 for all doctor, nursing and allied health consultation. All parties including doctors, nurses, pharmacists and RCHE staffs welcome and are confident to work under the new system. All the consultation records were saved in CMS system. Therefore, when CGAT patients was admitted to different hospitals, the medical records can be retrieved immediately, thus patient’s care can be greatly enhanced.
