Authors (including presenting author) :
Chan TC
Affiliation :
Queen Mary Hospital, Occupational Therapy Department
David Trench Rehabilitation Centre, Occupational Therapy Department
Introduction :
In order to utilise the known benefits of e-Documentation and reduce risk in clinical process, e-Documentation was being used in cases referred from A&E who require immediate treatment and transfer to DTRC for follow up.
Objectives :
The initiative was acting as communication and quality enhancement within Queen Mary Hospital (QMH) Occupational Therapy Department and Occupational Therapy Out-patient setting in Sai Ying Pun (DTRC). Patients referred from A&E department may require priority treatment after triage, they will receive occupational therapy treatment (splints, fall prevention, etc) in QMH at the earliest time-slot available. Then these patients will be transferred to Occupational Therapy Out-patient setting in Sai Ying Pun (DTRC) for further follow up treatment. The communication were previously done by transfer of hard copy and cross check of patient lists by fax. The process is now replaced with e-Documentation done by CMS station or iPad (mobile CMS). Therapist in QMH can use CMS and Mobile CMS (iPad) to key in patient assessment and treatment process using “Allied Health Progress Notes” function. Therapist in QMH can extract A&E cases intake form from “personal template” function in CMS or key in treatment progress in mobile CMS (iPad). Therapist in DTRC will be able to retrieve patient’s progress in CMS.
Methodology :
All therapist in QMH can take up this e-Documentation process change in the first month. Same CMS personal template was used as a guide by all therapist. All therapist in QMH and DTRC were able to adopt to the new process before June of 2020. A few pages of patient lists were sent to DTRC, therapist there can access patient’s data in CMS.
Result & Outcome :
This change in documentation process was rolled out and adopted by all therapist completely. More than 250 cases were recorded using this new documentation method. Adopting e-Documentation of this process utilises the known benefits of e-Documentation, including on-time, low risk passing of patient information across settings.
The e-documentation are accessible by all team members, instead of being an independent hand-written occupational therapy treatment progress notes. Both QMH and DTRC can access the episodic information for communication purpose. Also, it resolve the word legibility, damaged hard copy issue and is more environmentally friendly. The process also enhanced patient care as reported. For cases with fracture, the shared X-ray view and therapist education allow better understanding of current condition and effective patient communication.
This transformation of documentation procedure demonstrate the possibility of patient data transfer can be safe, efficient and reliable. One very large bulk of hard copy patient file transfer still exist between QMH and DTRC. Due to limited function of CMS personal template, it was difficult for e-documentation to work out effectively. In the near future, it may be possible the sole way of patient data between 2 centres will only be transferred in digital means.
