Implementing electronic patient documentation for Health and Social Care Professionals

Background: As with most Irish healthcare settings, clinical documentation in the author’s organisation was largely paper-based, resulting in a variety of problems for health and social care professionals (HSCPs), some of... [ view full abstract ]

Background: As with most Irish healthcare settings, clinical documentation in the author’s organisation was largely paper-based, resulting in a variety of problems for health and social care professionals (HSCPs), some of which had potential to lead to clinical risk for patients. These problems included difficulty finding and accessing notes in a timely manner, duplication of information, poor legibility, difficulty extracting information quickly and easily for audit/research purposes, ongoing storage issues.

Aims and objectives: The aim of the project was to develop and implement an electronic documentation system for HSCPs that would
• reduce duplication, standardise and improve data recording
• increase accessibility to data for audit/research purposes
• reduce paper filing and storage requirements
• increase accessibility of patient information for all members of multidisciplinary team
• begin to build one centrally located, life long patient record in line with national eHealth strategy

Description: The HSCPs, together with our organisation’s IT department, set out to design and implement an electronic based documentation system that would address the identified difficulties and result in a user friendly, efficient and effective record keeping system. Implementation included triaging referrals, documenting patient assessments and interventions, outcome measures, onward referrals to other professionals. Mobile handheld devices were used in some areas to enhance access to data recording and retrieval. Involvement of clinicians at all stages of the process and ongoing support have been important factors in ensuring success.

Impact of innovation: Staff and patient satisfaction levels with the electronic system are high. Patient information, which is easily legible and recorded in a standardised way can be accessed easily throughout the campus by multiple users at the same time. Information on a wide variety of patient data can be more easily reported for service planning and clinical research.

Conclusions and implications: Accurate recording of interventions in an electronic format is a challenge facing many healthcare professionals in the coming years. Initial experiences in our organisation with an electronic system for HSCPs have been positive and have allowed improved accessibility to patient information for clinical management, audit and research.