Authors (including presenting author) :
Ng TW, Wong WY, Cheung HL, Cheung SY, Law SY, Yip KT, , Lam SL, Chiang KH, Lai WK
Affiliation :
Physiotherapy Department, Shatin Hospital
Introduction :
Clinical documentation audit in physiotherapy department in Shatin Hospital and Bradbury Hospital have been implemented since 2016. It is an ongoing quality program to keep up our departmental standard.
Objectives :
This retrospective study aims to evaluate the quality of physiotherapy documentation in Shatin Hospital (SH) and Bradbury Hospice (BBH), to enhance good compliance in clinical documentation.
Methodology :
The study was conducted in 11/2018 4 Physiotherapy I and 3 Physiotherapy II colleagues were volunteered as auditors. In 2 randomly selected weeks from 29/10/2018 to 9/11/2018, the first 3 cases from 6 randomly selected discharged cases from each physiotherapist were retrieved from Medical Record Office (MRO) for clinical documentation audit. There were 22 audit items, covering 5 domains involving: general documentation, assessment process, care plan and delivery, care evaluation, discharge plan and ongoing care. The items were decided using “Manual of Good Practices in Medical Records Management” and “NTEC Guidelines on Medical Record Documentation“ as reference. Each item was scored “Y”, “N” or “N/A” according to the record audit form. The compliance rate of each item and overall compliance percentage of each staff were calculated. A briefing session was conducted to all staff for presenting the audit results and suggesting future recommendations.
Result & Outcome :
66 discharged reports from 22 staff were audited. The compliance of the 22 items ranged from 73.3% to 100%. 19 audit items achieved a compliance rate above 90%, which were higher than previous year (18 items only in 2017)
Three items : ‘ Correct mistakes clearly’ , ‘Appropriate use of abbreviations and symbols’ and ‘Problem identification and treatment plan related to fall’, the compliance rate were relatively low as 86.4%, 76.9% and 73.3% respectively. However, the first two items already scored higher than that in 2017 ( 79.5% & 11.65% ). 5 staff scored 100% across all items, while 7 staff have a compliance rate of less than 90%. Conclusion
Result of current year was more promising than 2017. We have further recommendations as follows: 1. Critical analysis on problem identification and decision on treatment plan should be strengthened.
2. More systematic information especially on the patient’s fall history need to be emphasized. 3. Where appropriate, items should be fully recorded in the boxes provided and unused forms should be removed. Documentation mistakes should be corrected according to the HAHO guidelines.
4. The uses of different abbreviations warrant further discussion but ultimately should follow the NTEC standardized abbreviation list. 5. Looking forward, we may consider to separate the current audit format into “documentation audit” and “process audit”.
Co-location with:
