Authors (including presenting author) :
Chan TM(1), Lai TK(1), Tse KP(1). Tsai KL(1)
Affiliation :
(1)Occupational Therapy Department, Haven of Hope Hospital
Introduction :
E-documentation is an important component for a smart hospital. Full e-documentation has been adopted by phases in Occupational Therapy Department, Haven of Hope Hospital for more than one year. In order to review and uphold the standard of e-documentation, evaluation work was done and quality feedback was gathered for better governance and quality improvement of E-documentation.
Objectives :
To improve the standard through evaluation and collect quality feedback on OT e-documentation in HHH.
Methodology :
2020 OTCOC Quality & Safety audit on OT outpatient documentation and HHH OT E-documentation reference guide were adopted as evaluation criteria with total 12 evaluation items were formulated. Evaluation were done in three phases from August 2024 to November 2024 with similar sampling method. In each phase, 30 patients' E-documentation (with >10 pieces and < 1 month) were randomly and evenly selected from 10 wards in HHH. Two feedback training sessions were given to all occupational therapists (OTs) in between with cue cards made and posted on the CMS sets as reminder. Moreover, two different questionnaires for internal OTs and external users (including doctors and nurses) with convenience sampling were designed to gather quality feedback on OT E-documentation.
Result & Outcome :
Total 1,124 pieces of e-documentation from 90 patients were evaluated. For initial result, 5 out of 12 items rated good (>90% achieved rate), 1 item with fair, 3 items with pass and remaining 3 items were not satisfactory (<60% achieved rate) (i.e. reason of referral, progress documented clearly and follow HHH OT E-documentation reference guide). After several improvement strategies, marked improvement was noted in the final evaluation. All 12 items rated satisfactory or above (>80% achieved rate) including 9 items rated good (>90% achieved rate) and OTs learned the way to document progress clearly in the same e-documentation for target readers. E-documentation comply well with reference guide. Total 22 questionnaires from OTs and 30 questionnaires from doctors and nurses were collected. All OTs prefer E-documentation for convenience, better legibility and shorter documentation time (reduce about 13% documentation time) and overall >80% with 7 out of 10 satisfaction score. For external users, >96% prefer E-documentation for better accessibility, legibility and understanding patient rehabilitation condition and overall 8.6 out of 10 satisfaction score. In summary, regular evaluation is worth to maintain/improve standard and compliance on E-documentation.
