Authors (including presenting author) :
Lam WC(1), Ho WF(1), Heung YM(1),Tam WS(1), Chan SL(2), Sham KY(2), Lau MY(2)
Affiliation :
(1)Department of Nursing, Cheshire Home, Chung Hom Kok, (2)Department of Administration, Cheshire Home, Chung Hom Kok
Introduction :
A medical record is a clinical, scientific, administrative, and legal document related to patient care that documents enough data in the order of events to justify the diagnosis and assurance of the treatment and the end result. The paper-based patient record is still the main source for information management in daily care delivery in Hospital Authority. In infirmary ward, we faced a big challenge in records keeping. With the patient long-term stay, they accumulated a large number of documents in their file. The patient’s files became bulky and easily broken. Lack of defined filing system caused data duplication or incomplete data, and misfiling. Even ward clerical staff and Medical Record Office (MRO) staff spent a lot of time in compiling the old record, the information is not organized and it is difficult to retrieve. MRO staff also needs to spend lots of time in grouping patient old record in MRO.
Objectives :
To enhance patient medical record filing properly and easy retrieval
Methodology :
To strengthening of the medical records management, Nursing Department and Medical Record Office joined hand to implement: All old paper files are replaced to a designated plastic file. It is spaced enough and toughly. 7 different colour dividers to separate different categories. Each divider printed on category information for easy filing. Each patient has two files. One is active file (green bed number label) for clinical use currently; another one is in-active file (Orange bed number label) keeping in cupboard for back up in ward. Primary nurses are responsible to put the old medical record to in-active file. The flow of Ward Medical record return to MRO also reviewed. All old record into the in-active file for temporarily storage in ward designated cupboard with lock. Ward clerk would transfer the whole in-active file to MRO twice a year. Then, MRO would return the empty file to ward within 2 weeks. MRO keep the patient record by period for easy retrieve and also simplified the filing method. Red dot was marked on the bed number label for the patient under Guardianship order. Another important message or documents e.g. “Advance Directive Order”, “Do Not Attempt CPR (DRACRP) were put on the front page of file for on call doctor easily access and be alert.
Result & Outcome :
Result / Outcome
Satisfactory survey was performed in December 2018, 100% staff recognized that new divider of file could facilitate filing. 98% of staff found the weight of file is lighter as old medical records were temporarily storage in ward. Moreover, 100% staff was aware that patients under guardianship or advance directive order after implementation. No any related incident happened. On the other hand, MRO staff can save 0.5 hour to handle one patient old medical record file after the new system implemented. As a result, it is estimated 190 hours among MRO staff would be saved yearly. Conclusion
A clear definition of filing system ensures patient's medical records easy retrieval and contributes to decrease misfiling at the hospital and ensures continuity of care.
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