Authors (including presenting author) :
Hung SY, Cheung PH, Chou PK, Tsui PN, Cheung YHK, Leung WM, Wong MYM, Wong MSM
Affiliation :
Department of Family Medicine and Primary Healthcare, Hong Kong East Cluster
Introduction :
Nursing documentation is crucial to high quality, effective and safe nursing care practice. Structured nursing documentation provides accurate information, reflects nursing intervention including assessment, planning, implementation and evaluation of patient outcomes as well as legal documents.
There are 3 outlying island (OLI) General Out-Patient Clinics (GOPC) in Hong Kong East Cluster, including Peng Chau (PC), North Lamma (NL) and Sok Kwu Wan (SOKW) GOPCs which provide First Aid Post (FAP) service to local residents with emergency conditions in addition to general outpatient clinic service. PC and NL clinics also operate 24 hours FAP service which involves lots of communication and collaboration with different stakeholders such as Fire Service, Police, Government Flying Service and Pamela Youde Nethersole Eastern Hospital Accident and Emergency departments. The average attendance of FAP in 3 OLI clinics were over 600 cases per year.
Nursing staff need to cope with emergency situations after clinic operation hours when no medical staff on duty. There was no standard template of nursing documentation for FAP cases in Clinical Management System (CMS), nurses documented the information by free text with different format.
Objectives :
1.Review and standardize FAP nursing documentation in CMS
2.Improve and align nursing documentation for FAP cases
3.Serve as a reference guide for nursing assessment and management
4.Enhance effective communication among all health care stakeholders
Methodology :
1.Reviewed FAP nursing documentation of cases from Jan 2022 to Apr 2022, categorized the cases into similar scenarios.
2.Prepared 4 structured nursing documentation templates and uploaded in CMS in May 2022.
3.Provided briefing to all nurses.
4.Conducted survey to collect feedback from OLI nurses and doctors in Dec 2022.
Result & Outcome :
Since June 2022, FAP nursing documentation was standardized with 4 commonly used templates categorized as follows: General case, Trauma/Injury case, Obstetric case and Cardiopulmonary resuscitation case. The templates were uploaded to CMS.
Questionnaires were collected from OLI nurses and doctors. All agreed that the templates were user friendly and comprehensive, facilitated FAP nursing documentation and enhanced communication.
Proper documentation with relevant information on FAP notes serves as an effective communication amongst health care colleagues, internal review and safeguard quality nursing care.
