Authors (including presenting author) :
To MT(1), Cheung KY(1)
Affiliation :
(1)Accident and Emergency, United Christian Hospital
Introduction :
Vital signs monitoring is a fundamental patient care activity. Timely and accurate documentation promotes patient safety by identifying abnormalities and enhancing clinical decision making. Our department faces challenges to high occupancy and turn- over rates, thereby manual documentation of vital signs findings is labor- intensive and prone to different types of documentation errors. With the support of hospital management and concerted efforts with different departments, the auto- charting system is successfully implemented in our department. It is an electronic documentation system which captures patients’ vital signs at the point of care and generates electronic vital signs charts. Healthcare staffs could access patients’ clinical findings via different electronic devices terminals by login clinical dashboard. The system is innovative and re-engines workflow, we evaluate the implementation process and achievement of it in order to provide referential experience.
Objectives :
(1) To improve efficacy of vital signs monitoring; (2) To reduce documentation errors; (3) To improve patient safety.
Methodology :
A cross- sectional study with descriptive, correlation design was employed. Pre and post implementation data were compared. We collected data from nurses and patient care assistants. Outcome measures were categorized as (1) Data omission, unreadable data and transcription errors in vital signs documentation; (2) Satisfaction survey.
Result & Outcome :
Nearly 100 samples of manual charts and electronic charts were reviewed respectively. We noted that documentation errors were significantly reduced after implementing auto- charting system. 47 questionnaires were collected. Feedback of nursing staffs in utilizing auto- charting system were positive and supportive. They were affirmative that auto- charting system streamlined the workflow and prevented avoidable errors.
To conclude, the auto- charting system successfully replaced manual vital signs documentation and was effective in improving efficacy and patient safety of vital signs monitoring.
