Authors (including presenting author) :
Wong YM (1), Hwang LM (2), Chan CH (2), Chan CY (1), Wong MC (1)
Affiliation :
(1) Clinical Oncology, Tuen Mun Hospital, New Territories West
(2) Palliative Home Care Team, Nursing Services Division, Tuen Mun Hospital, New Territories West
Introduction :
Quality nursing documentation is essential for patient safety and effective care delivery, enhancing communication among healthcare providers and supporting clinical decision-making.
At Tuen Mun Hospital, CMS has standardized nursing notes, significantly improving the consistency and accessibility of patient information. In 2023, we introduced the Patient Assessment Form for Palliative Care (PAF(PC) ) within the CMS for all palliative oncology cases. To facilitate this transition, training sessions were conducted, including recorded Zoom training. We provided templates and real-life examples to illustrate the importance of accurate documentation, standardizing practices and reinforcing the use of the PAF(PC).
Regular nursing documentation audits are vital for ensuring compliance with established standards and identifying areas for improvement. By systematically reviewing documentation, we ensure it meets regulatory requirements and supports high-quality patient care. These audits promote continuous quality improvement, enabling us to refine our training based on identified gaps.
Objectives :
The primary objective of this audit was to evaluate the quality of electronic nursing records using a standardized audit form. This assessment aimed to identify areas for improvement, allowing for tailored strategies to enhance documentation practices.
Methodology :
A randomized clinical audit was conducted at Tuen Mun Hospital, focusing on new cases within the palliative service. A standardized audit form, based on core nursing standards, was developed for consistency.
On June 12, 2024, a briefing session was held to educate staff on the key elements of the audit form. The audit involved a retrospective review of 15 patient records from July 1 to July 31, 2024, across various palliative care settings, including the H1 Ward, Day Hospice Centre, and Home Care Team.
Result & Outcome :
The audit yielded satisfactory results, highlighting four critical points that achieved 100%, indicating staff understanding of the audit form's key elements after the briefing session.
However, several areas for improvement were noted:
i) Lack of documentation regarding patient responses after introducing other disciplinary services.
ii) Missing a remark icon and failing to highlight individuals living with the patient in the family tree on the PAF(PC).
iii) The "Updated" and “Sign” buttons were not clicked on the PAF(PC).
iv) Failure to use the correct symbols in the family tree documentation.
Feedback sessions were conducted with individual staff to address these issues. Overall, while timely documentation was noted, it is recommended to continue monitoring the PAF(PC) and to educate staff on proper documentation within this platform. Regular audits are also suggested for continuous improvement.
