Authors (including presenting author) :
Lai ML(1),Leung YF(1), Lau YY(1), Wong PH(1),Tse KY(1), Kwok FL(1), Lam PH(1), Chiu CWH(1), Leung SY(1), Hui EMT(1), Hui E(1)(2)
Affiliation :
(1) Departement of Family Medicine, NTEC (2) Department of Medicine & Geriatrics of Shatin Hospital, NTEC
Introduction :
The demand for wound care service was tremendous in GOPC. Nurses had only 10-15 minutes to complete one dressing procedure. To enhance the wound documentation, NTEC GOPCs have initiated electronic wound documentation in Clinical Management System (CMS). Wound care templates were set up to facilitate the record entry. However, root cause analysis of several incidents related to wound care revealed that the wound documentation was incomplete and inaccurate which lead to break of continuity of wound care. The wound documentation templates were too comprehensive and detail that nurses could not complete in the short procedure time. Different interpretation of wound notes further worsened the inconsistency of wound care. It is imperative to address the content of the wound documentation. Simplification and standardization of wound care templates were conducted to enhance safety and continuity of wound care.
Objectives :
1.To standardized wound care templates among NTEC GOPCs for alignment of practice 2.To develop concise and precise wound care templates for enhancing patient safety and the continuity of care. 3.To facilitate better communication
Methodology :
The Plan-Do-Check-Act cycle was employed to guide the planning and implementation of the revision of wound documentation. A task group involving 3 ward managers, 3 wound nurses and 6 registered nurses from 9 GOPCs in New Territories East Cluster (NTEC) was set up to review the current practice of wound documentation. The task group identified the mandatory items to be included in the wound templates e.g. number of packing material removed and applied. After the new wound templates were developed, all the stakeholders were informed of the revised wound templates and training was provided for all nurses. From Aug till Dec 2019, the on-site coaching and supervision of using the new wound templates were implemented. Daily audit of 5 wound documentation in each clinic was conducted to monitor the compliance, accuracy and completeness of documentation.
Result & Outcome :
Result & Outcome
2,736 clinical supervision of wound care documentation and 948 on-site coaching were performed during Aug till Dec 2019. The wound care documentation audit among NTEC clinics was implemented in May 2020. The overall compliance was 99.35%.
Conclusion
With the simplicity of wound templates, nurses reflected they have adequate time to complete the wound document and they showed competency and consistency in using the new wound templates. In addition, the precise and concise documentation enhance better communication on wound condition and continuity of care. In conclusion, a concise and precise wound documentation is better than comprehensive and incomplete documentation
