Authors (including presenting author) :
Li MNC (1), Chan SF (1), Lau KYG (1), Wong SN (1), Lai YM (1), Woo SMM (1)
Affiliation :
(1) Community Care Services, Queen Mary Hospital, HKWC
Introduction :
The quality of nursing documentation is evidently a prerequisite for safe, ethical and sustainable care to the health care. It is especially important for patient involvement in the care journey. Previously, patient medical records in HKWC Community Nursing Services are written on paper. However, the problem of written notes are at risk of misinterpreting and misplacement. This may raise a concern about medico-legal implications. Thus, a transition from paper to electronic documentation together with the structured record of patient care has been introduced to replace patient's paper notes with the aim of (1) improving and standardizing clinical documentation of patients under the care by community nurses; (2)boosting clinical information sharing and (3) providing a more reliable record-keeping system. A staff survey was undertook to investigate the opinion of community nurses after implementing the electronic documentation.
Objectives :
The main objective of this user survey was to gather users' opinion, gauge their satisfaction and address any concerns they had regarding the electronic documentation.
Methodology :
The analysis is based on a survey carried out from June to July 2022. The survey questionnaire consisted of 6 questions to which responded the community nursing staffs from Queen Mary Hospital in HKWC. The questionnaire was distributed in google form and contained 5 closed and 1 open type questions. The survey was anonymous and lasted for 2 months. A questionnaire with QR code was initially sent out and the response rate was 88 %. The first five questions dealt with the kind of the measurable effect in clinical documentation, i.e. timing, information quality, system quality and overall satisfaction to the new documentation system. The last question was an open type of question dedicated to possible comments or concerns. Descriptive qualitative research method was used to carry out the analyses.
Result & Outcome :
When applying the measurable effects in using the electronic documentation, several findings were observed. In terms of timing, more than two-thirds (65.4%) reported spending less than 2 hours per day on documentation. Another measurable effects of the information quality regarding the e-note content and its format, over 73 % of survey participants responded that the nursing process documentation including assessment, goal setting, planning and intervention is clear and complete. Respondents had far greater affirmative response towards the implementation of new documentation system with an overwhelmingly larger proportion of them, over 96%, agreeing that they were satisfied to the electronic documentation. However, survey results pointed out a need for sufficient computers for the department. It can be concluded from this survey results that electronic documentation is an effective way to improve the quality of nursing care in terms of the quality of nursing documentation and time efficiency. Nurses also felt satisfied after using the electronic documentation.
