Page 65 - HA Convention 2016 [Abstracts (Day 1)]

Service Enhancement Presentations HOSPITAL AUTHORITY CONVENTION 2016

F3.6 Clinical Safety and Quality Service I 14:30 Room 421

Admission Documentation in One Click
Ku BPS, Pang JYW, Chui AKF, Cheung NT, Ho WKH, Cai YK, Cheung AWM
Information Technology and Health Informatics Divisoin, Hospital Authoriy Head Office, Hong Kong

Introduction Tuesday, 3 May

There has always been keen demand for in-patient service in Hospital Authority (HA) and admission of patients inevitably
becomes a routine and important day to day work for clinicians. Besides the clinical arrangement for admission, there is also
a keen demand for proper documentation which was essential for ward staff to follow up on the patients. A standardised
printout containing comprehensive clinical information and suiting the workflow of clinicians in admission procedure is
proposed. To facilitate clinicians to prepare up-to-date and quality documentation in such process, utilisation of Health
Information Technology to develop such Admission Documentation printout was planned.

Objectives

(1) To support clinicians in the admission workflow and coherent to existing workflow; (2) to enhance inter-disciplinary and
intra-disciplinary communication; and (3) to improve clinical documentation through enhancement of printout.

Methodology

In order to have a complete understanding of the requirements for development of this Admission Documentation printout,
detailed workflow analysis was conducted, and consultation to relevant working groups for expert opinion was carried out.
The function leveraged on existing Progress Note and interfaced with clinical information of other systems including: (1)
Allergy data; (2) investigation ordered with interface to Generic Clinical Request System (GCRS); (3) drug prescribed through
Inpatient Medication Order Entry after completed writing Progress Note during admission of a patient. By simply one click
on the newly designed “Admission Note” button, the clinician could obtain a printout including the content of the Progress
Note together with the interfaced data with reference to the date and time of admission. In addition, the printout showed
appropriate heading of Admission Note so that the printout could be included in patient’s medical record.

Results

The function was rolled out to all Hospital Authority hospitals in March 2015. Positive comments were received from clinicians
including saving time in preparing the admission documentation, the comprehensive information facilitated communication,
and the printout served well in the requirement for improved clinical documentation. The function was widely used in HA
hospitals since rolling out.

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