A journey to create a new patient-record system

Area of Science:

• Healthcare Informatics
• Clinical Documentation Improvement
• Organizational Change Management

Background:

• Traditional patient record systems often present fragmented information.
• Lack of integration between documentation and care models hinders interdisciplinary collaboration.

Purpose of the Study:

• To redesign the patient record system at West Park.
• To enhance patient-centered documentation.
• To integrate the system with a collaborative care model.

Main Methods:

• Focused on the patient's narrative in system redesign.
• Streamlined numerous chart forms.
• Integrated documentation with a new care model.
• Involved stakeholders throughout the process.

Main Results:

• Developed a patient-story-centric record system.
• Achieved streamlined charting processes.
• Facilitated closer collaboration among clinical disciplines.
• Successfully adapted the system to the organization's specific needs.

Conclusions:

• Redesigning patient record systems with a focus on the patient's story and interdisciplinary collaboration can improve documentation and care delivery.
• Stakeholder involvement and organizational adaptation are key to successful system implementation.
• Continuous refinement of charting forms is essential for ongoing optimization.