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Improving clinical documentation: introduction of electronic health records in paediatrics
1Department of Paediatrics, University Hospitals of Derby and Burton NHS Foundation Trust, Queen's Hospital, Belvedere Road, Burton Upon Trent, UK.
Insights
Implementing electronic health records in paediatrics improved clinical documentation and patient care. Staff overwhelmingly supported the new electronic system, citing enhanced quality, usefulness, and practicality in record-keeping.
Area of Science:
- Healthcare Informatics
- Clinical Documentation Improvement
- Paediatric Medicine
Background:
- Traditional paper-based medical records present challenges including illegibility and misplacement, potentially impacting patient care and leading to medico-legal issues.
- Electronic patient records (EPR) are increasingly adopted to enhance reliability and efficiency in healthcare record-keeping.
- The paediatric department at Queen's Hospital Burton utilized a hybrid system with paper notes for direct clinical encounters and EPR for laboratory, imaging, and prescriptions.
Purpose of the Study:
- To improve and standardize clinical documentation for paediatric admissions and ward round notes.
- To develop electronic proforma for initial paediatric clerking, ward rounds, and patient reviews.
- To assess the impact of implementing electronic health records on clinical documentation and staff perceptions.
Main Methods:
- Development of electronic proforma for paediatric clerking and ward reviews.
- Implementation of the electronic proforma within the paediatric department.
- Conducting a staff survey to evaluate opinions before and after the implementation of electronic health records.
Main Results:
- The quality improvement project successfully enhanced clinical documentation on paediatric wards.
- Patient record-keeping was improved, clinical information sharing was boosted, and the patient journey was streamlined.
- The project met 100% of the standards set by the Royal College of Physicians' multidisciplinary record-keeping audit tool.
- A staff survey revealed overwhelming support from doctors, nurses, and healthcare support workers for the quality, usefulness, completeness, and practicality of the electronic records.
Conclusions:
- The implementation of electronic proforma significantly improved clinical documentation and record-keeping in the paediatric department.
- Electronic health records were perceived positively by healthcare professionals, enhancing efficiency and patient care.
- Standardized electronic documentation supports better clinical decision-making and interdisciplinary communication.
Abstract:
Medical records are crucial facet of a patient's journey. These provide the clinician with a permanent record of the patient's illness and ongoing medical care, thus enabling informed clinical decisions. In many hospitals, patient medical records are written on paper. However, written notes are liable to misinterpretation due to illegibility and misplacement. This can affect the patient's medical care and has medico-legal implications. Electronic patient records (EPR) have been gradually introduced to replace patient's paper notes with the aim of providing a more reliable record-keeping system. It is perceived that EPR improve the quality and efficiency of patient care. The paediatric department at Queen's Hospital Burton uses a mix of paper notes and computerised medical records. Clinicians primarily use paper notes for admission clerking, ward rounds, ward reviews and outpatient clinic consultations. Laboratory tests, imaging results and prescription requests are executed via the EPR system. Documentation by nurses is also carried out electronically. We aimed to improve and standardise clinical documentation of paediatric admissions and ward round notes by developing electronic proforma for initial paediatric clerking, ward rounds and patient reviews. This quality improvement project improved clinical documentation on the paediatric wards and enhanced patient record-keeping, boosted clinical information-sharing and streamlined patient journey. It fulfilled various generic multidisciplinary record keeping audit tool standards endorsed by the Royal College of Physicians by 100%. We undertook a staff survey to investigate the opinion before and after implementing the electronic health record. Doctors, nurses and healthcare support workers overwhelmingly supported the quality, usefulness, completeness of specified fields and practicality of the electronic records.
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Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.