Page 219 - Hospital Authority Convention 2018

Service Enhancement Presentations

F7.5 Committed and Happy Staff 13:15 Room 421

Electronic Documentation of Patients’ Records to Reduce Files Handling by Clerical Staff at Outpatient
Physiotherapy Department of Pok Oi Hospital
Ng CL, Tam MP, Tse CS, Chan LC, Law YT
Physiotherapy Department, Pok Oi Hospital, Hong Kong HOSPITAL AUTHORITY CONVENTION 2018

Introduction
Handwritten documentation of patients’ physiotherapy records was a traditional practice in the past few decades. Our clerical
staff had to sort out around 300 patients’ files on physiotherapy appointment each day. They had to file back the patients’
files after documentation done by the physiotherapists. This process was time-consuming and might induce repetitive stress
injuries to the clerical staff during filing procedure. In view of the situation, electronic documentation of patients’ records
was implemented at the Outpatient Physiotherapy Department (OPD) of Pok Oi Hospital (POH) to reduce the daily number of
patients’ files being handled by clerical staff.

Objectives
(1) To evaluate the effectiveness of electronic documentation on handling patients’ records by clerical staff; and (2) to report
the compliance of electronic documentation by physiotherapists.

Methodology
Electronic documentation through Clinical Management System (CMS) has been implementing at the OPD of POH since 1
September 2017 for all individual cases. Only the daily new patients’ files were sorted out by clerical staff for physiotherapists’
recording. There is no need to sort out the patients’ files with subsequent appointment. The number of patients’ files being
handled by clerical staff was compared before and after the implementation of electronic documentation. An audit on
electronic documentation input was conducted to the nine full-time OPD physiotherapists after implementation of electronic
documentation for one month. All attended cases of a randomly selected date were recruited for documentation audit. Each
physiotherapist can audit the electronic documentation input of their peers except the cases of their own.

Results
Before implementation of electronic documentation of patients’ records, clerical staff had to spend about 180 minutes to
handle around 300 patients’ files daily. After the implementation of electronic documentation, only the new patients’ files have
to be handled. Therefore, the number of patients’ files being handled was reduced from 300 to around 40. The time required
for files handling was reduced from 180 minutes to around 25 minutes. For the documentation audit, a total of 250 patients’
records were evaluated. There were 248 cases with electronic documentation resulting in 99.2% of input in the CMS. It
showed a high compliance rate of out-patient physiotherapists in using electronic documentation. Two cases were found to
have missing sign off (that was incomplete documentation). The implementation of electronic documentation has reduced
the number of patients’ files handled by clerical staff. This improvement project was effective in minimising the stress and
workload to the clerical staff. The time saved in files handling can be spent for other clerical work. On the other hand, regular
documentation audit is recommended to ensure the quality of our service. Tuesday, 8 May 2018

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