Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service I (Projects aiming to improve efficiency and effectiveness of care delivery to meet international standards)
Authors (including presenting author) :
Sit SYC (1), Wong YOK (1), Chiang KHW (1)
Affiliation :
(1) Physiotherapy Department, Shatin Hospital
Introduction :
Documentation of service provided by Physiotherapists is necessary for legal recording and facilitation of communications among multi-disciplines. Traditionally, documentation was in written format. However, various problems existed in the past, such as, poor handwriting leading to misunderstanding and frequent corrections required, inappropriate use of abbreviations and unclear documentation leading to poor documentation in problems and treatment plans in details. Electronic documentations in physiotherapy department was started in Shatin Hospital since 2018 for discharge summary and inter-hospitals transfer communication. To tackle the problems brought by written documentations with incorporation of strategic goal of Smart Hospital, full e-documentation in daily in-patient physiotherapy assessment and treatment was implemented in phases in 2023.
Objectives :
To compare the compliance and quality of clinical documentation on in-patient physiotherapy assessment and treatment between written and electronic format.
Methodology :
Clinical documentation audit was carried out for both written and electronic in-patient documentations in November 2023. Three written and three electronic documentations of each physiotherapist were randomly collected for audit. The compliance of 23 items under the scopes of general documentation, assessment process, care plan and delivery, discharge plan and on-going care, and care evaluation was evaluated.
Result & Outcome :
A total of 93 written and 93 electronic in-patient documentations were collected for audit. There was significant difference of compliance rate found in the following items: Appropriate use of abbreviation and symbols (Written form 52% versus electronic form 92%), Problems identification and treatment plan (Written form 78% versus electronic form 99%) and Multidisciplinary communication (Written form 82% versus electronic form 99%). The compliance of Proper correction of mistakes in written form was observed to be 85% versus problem not existed in electronic form.
Electronic documentation facilitated quality documentation which was reflected by the higher compliance rate in the clinical documentation audit. The higher compliance rate may be due to the benefits brought by electronic documentation form, such as, pre-filled relevant information in the documentation template and easily accessible documentation on electronic system by multidisciplinary staff. To facilitate usage of electronic documentation, templates for different disease groups were designed. However, difficulties encountered during creation of templates due to the limitation of the existing system. Together with the stepwise renovation of clinical management system, implementation
