Authors (including presenting author) :
Kong TL(1),Leung GL(1),Ku CM(1),Chan WY(1),Lam KM(1),Lam WY(1),Yuen SY(1)
Affiliation :
(1) Specialist Out Patient Department, Pamela Youde Nethersole Eastern Hospital
Introduction :
Some patients require regular injection treatment for their illnesses. This usually begin at Specialist Out Patient Clinic (SOPC), then carry on periodically at General Out Patient Clinic (GOPC) or by Community Nurses Services (CNS). At SOPC of Pamela Youde Nethersole Eastern Hospital (PYNEH), physician prescribe the treatment by an injection form (IF), and then direct the patient to nurse. Nurse document on the IF after injection, and then hand over to patient to continue the injection at GOPC or by CNS.
However, some patients were unable to present the IF when they attended GOPC or were visited by CNS for their next injection. And some of them even were unable to recall the details of last injection. In order to ensure medication safety, nurses from different departments may call PYNEH SOPC for the injection information of a particular patient. It is time and manpower consuming to trace the paper-based record.
At 1Q 2019, the SOPC Medication Safety Team developed 9 Electronic Nursing Consultation Note (ENCN) Templates in Clinical Management System (CMS) for the frequently used injection records, aims to improve documentation and better tracing injection record via CMS. Nurses can choose a suitable template for documentation after performing an injection. The templates were firstly on trial at L1 East clinic for one week to generate experience and evaluation. Nurses training session and demonstration were provided before rolling out to all clinics. Since May 2019, all injections were documented in CMS by using corresponding ENCN Template.
Objectives :
To review the compliance of using ENCN for injection documentation.
Methodology :
An evaluation form was developed to review the compliance of using ENCN documentation. The audit was carried out by the SOPC Medication Safety Team retrospectively from 20 May to 20 June, 2019. Quota sampling method was adopted in order to collect ENCN from different clinics.
Result & Outcome :
There were 30 injection records collected. All items were 100% completed except a nurse entered the initial of counter-check nurse. It is recommended to reinforce nurses to document the counter-check nurse's name in full instead of initial.
There is around 11,000 times medication injections performed at PYNEH SOPC per year. The implementation of ENCN is able to achieve an effective communication between health-care professionals. The limitation of this audit was small sample size. However, it is advised to monitor the use of ENCN regularly to ensure the compliance.
