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 I (Projects aiming to improve efficiency and effectiveness of care delivery to meet international standards)
Authors (including presenting author) :
Leung LM (1), Choy KL(2), WONG CS(3), Loon TK(4)
Affiliation :
(1)Central Nursing Division, North Lantau Hospital, (2) Medicine & Geriatric Department, North Lantau Hospital, (3) Accident and Emergency Department, North Lantau Hospital, (4) Ambulatory Surgery and Endoscopy Centre, North Lantau Hospital
Introduction :
eDocumentation (eDoc) is an electronic platform to input and view of multidisciplinary clinical notes in one stop, which can also synchronize between CMS on mobile devices and desktop workstation. NLTH is the first hospital in KWC which fully implemented eDoc in all in-patient wards since 12 June 2023, to perform daily ward round smarter with paperless clinical notes for multi-disciplines on this electronic platform. To promote the continuity of nursing care and improve the quality of nursing care documentation, standardized documentation templates have been introduced in eDoc for certain nursing care or procedure with a focus to systematically document nursing intervention and process. The templates provide structured and consistent nursing documentation and integrate the nursing process in this context which to be shared by every NLTH Nursing Staff in eDoc. The templates also provide nurse with the guidance on the clinical judgement that facilitate the risk management in patient care delivery thus to maintain the quality and safety of patient care. After 4-week implementation of the standardized template, a staff survey was conducted to gather staff satisfaction on the application and make adjustment of template content according to their experiences. A compliance check on the template utilization was also conducted to evaluate the effectiveness.
Objectives :
1. To align the essential elements of nursing documentation in eDoc
2. To formulate hospital-based template in eDoc especially those common and essential nursing care or procedures so as to streamline nursing documentation
Methodology :
1. Conduct Staff survey by questionnaire to gather staff insights in the context
2. Conduct compliance check on using the standardized template for nursing care and procedures by retrospective documentation review
Result & Outcome :
From late Nov to Dec 2023, nursing staff from 4 in-patient wards completed the survey after launching the standardized templates. Results as below:
The result of the compliance check on using the standardized template for nursing care and procedures by retrospective documentation review is illustrated.
Upon retrospective review of the documentation in eDoc, nursing documentation related to patient discharge was noted with multiple entries. Multiple attempts to contact relative/ aged home or referral of community services, which the standardized template may become inapplicable to the situation that may hinder staff to adopt the discharge template in eDoc.
Conclusion:
In conclusion, the standardized templates not only help nursing staff to maintain proper clinical documentation practice but also reinforce staff to deliver quality care which follow through with the nursing process.
