Authors (including presenting author) :
Lee A(1), Hwang LM(1), Wong PLC(1), Cheung KW(1), Wong WT(1), Chan WY(1), Chan CH(1), Cheng HW(2)
Affiliation :
(1) Palliative Home Care Team, Nursing Service Division, Tuen Mun Hospital, NTWC, (2) Medical Palliative Medicine (MPM) Team, Department of Medicine and Geriatrics, Tuen Mun Hospital, NTWC
Introduction :
Effective nursing documentation in electronic patient records (EPR) is essential for ensuring high-quality patient care and safety. This audit examines the nursing documentation in EPR of 437 deceased cases at Palliative Home Care Team (PHCT) of New Territories West Cluster (NTWC), identifying strengths and areas needing improvement.
Objectives :
1. To assess the quality of nursing documentation in EPR for deceased patients. 2. To identify discrepancies and areas needing enhancement. 3. To develop recommendations for improving documentation practices.
Methodology :
The audit was conducted from June to July 2024, focusing on 437 cases of deceased patients from 1 April 2023 to 31 March 2024. A standardized audit tool evaluated documentation based on criteria such as completeness, accuracy, and adherence to best practices. Data were collected and analyzed to identify trends and areas requiring attention. In addition, focus groups with nursing staff were conducted to gather insights into challenges encountered during documentation.
Result & Outcome :
The audit revealed that 76% of documentation met the established guidelines, indicating satisfactory performance overall. Key issues identified included missing data (15%), inconsistent terminology use (12%), and delays in updating patient information (9%). The analysis highlighted the need for clearer guidelines and additional training for nursing staff. An improvement plan was implemented, focusing on the following strategies: 1. Standardized Training: Mandatory workshops on best documentation practices in EPR. 2. Guideline Development: Creation of a comprehensive documentation manual to ensure consistency across all clusters. 3. Regular Audits: Establishment of bi-annual audits to monitor compliance and gather ongoing feedback. In the month following the audit, compliance with documentation standards improved by 25%, demonstrating the effectiveness of the interventions. This audit underscores the importance of systematic evaluation in enhancing nursing documentation within electronic patient records. The findings suggest that targeted training and standardized practices are crucial for maintaining high-quality documentation, ultimately leading to better patient care outcomes. Future efforts should focus on sustaining these improvements and further refining documentation practices.
