Authors (including presenting author) :
Chan WCD(1), Lau M(1), Yue SYA(1), Ip WMK(1), Leung YSJ(1), Kay KPR(1), Liu YTE(1)
Affiliation :
(1) Occupational Therapy Department, Shatin Hospital
Introduction :
Clinical documentation is an important part of work of occupational therapists (OT). It is therapist's responsibility to document patient’s assessment results and progress from initial assessment and throughout the rehabilitation process to discharge. Traditionally, OT fill paper assessment forms and write progress on paper progress note. Paper documentation has the problems of paper storage, accessibility of the records and clinical handover. To align with the strategic direction of Hospital Authority of Smart Hospital in electronic documentation (e-documentation), Shatin Hospital (SH) Occupational Therapy Department (OTD) had developed a web-based electronic form (e-form) to enhance clinical documentation efficiency and implemented paperless practice.
Objectives :
Using a web-based e-form to enhance clinical documentation efficiency; facilitate clinical handover; promote paperless practice and standardize the quality of clinical documentation.
Methodology :
E-documentation working group had been set up in Jan 2021 aiming at establishing the infra-structure in SH OTD to prepare for e-documentation implementation including network setup, mobile devices and Clinical Management System (CMS) workstation procurement. The web-based e-form was operated on mobile devices which included data base and all the functional and specific assessments including Medical & Geriatrics; Stroke; Neuro-surgical; Respiratory and Palliative care. Therapist could use their mobile devices to input the assessment results through pre-set field or dropdown lists to minimize text input and speed up the documentation process. After finishing the e-form, it could be saved and converted into a completed assessment form with standardized format for therapist to copy into the Occupational Therapy Progress Note in CMS.
Result & Outcome :
From April 2022, OT in SH had kick started the use of the web-based e-form for clinical documentation. After the trial period of 2 months in June 2022, OT could use the web-based e-form to replace all paper forms to enhance paperless practice in clinical documentation. Also starting from December 2022, Clinical Document Scanner App (DSA) was launched in HA CMS mobile. DSA can help to scan and share (not-yet electronic) clinical document to CMS. DSA together with web-based e-form, OT can practice paperless clinical documentation. In addition, OT can also attend case conference using HA Allied Health iPads to access patient’s progress note in CMS for reporting. It also facilitates clinical handover for OTs in different hospitals. Furthermore, the output text file e-form has standardized format and content of assessment results which can maintain the standard of clinical documentation of OTs.
