Proposed Topic (Most preferred): :
Clinical Safety and Quality Service I (Projects aiming to improve efficiency and effectiveness of care delivery to meet international standards)
Proposed Topic (Second preferred): :
HA Young Investigators Session (Projects to be presented by HA staff who had joined HA for 10 years or less)
Authors (including presenting author) :
Raymond LEUNG (1), Karin CHOW (1), TMH Stroke Nursing Team
Affiliation :
(1) Stroke Nursing Team, Acute Stroke Unit, Department of Medicine and Geriatrics, Tuen Mun Hospital
Introduction :
Stroke patients require interdisciplinary care from neurologists, stroke nurses, and allied health professionals. However, each discipline performs their own assessment, which may lead to information gaps and inefficiencies. The Tuen Mun Hospital Stroke Nursing Team piloted the use of standardized electronic nursing documentation since 2020 to promote patient information sharing among the interdisciplinary team for better patient care. In 2023, the content and usage of the electronic documentation was revised to enhance communication with rehabilitation specialists to optimize the arrangement of stroke rehabilitation bed to fit patients’ needs.
Objectives :
To demonstrate the role and impact of standardized electronic nursing documentation in interdisciplinary collaboration of stroke care.
Methodology :
Qualitative interviews of major stakeholders who use the nursing documentation, including stroke nurses, neurologists, physiotherapists, occupational therapists, speech therapists, and rehabilitation specialists.
Result & Outcome :
The standardized electronic nursing documentation consists of premorbid health history, details of current stroke episode, physical assessment by stroke nurses, and individualized nursing care plan and health education. The revised template was reviewed by a panel of stroke nurse specialists and rehabilitation specialist. It focuses on assessing patients’ premorbid social function and discharge planning discussion conducted by stroke nurses to identify major caregiving hurdles anticipated by family members. The template was rolled out for clinical use since March 2023.
The revised template was use for construct discharge plan for all stroke patients admitted to acute stroke unit since implementation, with over 1000 completed documentations at time of evaluation.
The qualitative interviews revealed that the standardized electronic nursing documentation enhanced the information sharing, understanding, and efficiency among the interdisciplinary team of stroke care. Stroke nurses reported empowerment and guidance through their creation of nursing notes. Stroke neurologists appreciated the documentation of neurological signs and onset time of stroke. Allied health professionals found the documentation useful in understanding patients’ social and demographic background and index event. Rehabilitation specialist recognized the assessment and discharge planning done by stroke nurses, which helped prioritize rehabilitation resources for stroke patients. All interviewed colleagues agreed the information sharing enhanced efficiency.
The standardized electronic nursing documentation is an effective tool to enhance interdisciplinary collaboration in stroke care. It improves the quality and continuity of patient care, and facilitates the optimal use of rehabilitation resources.
