Authors (including presenting author) :
Lee KY, Poon WK, Lau CM, Yeung HW, Chang SPV, Yue SY
Affiliation :
Occupational Therapy Department (OTD), Shatin Hospital (SH)
Introduction :
Electronic health document is progressively being deployed in clinical setting to ease great demand on paper work, improve accuracy of documentation & clinical handover. PMOM is an electronic health record system newly launched in 7/2018 in Psychiatric OTD in SH. This system contains electronic standardized assessments, outcome measures & preset report documentation templates which allow timely data entry and facilitate adding up assessment scores. The PMOM also promotes accessibility as occupational therapists can access to the PMOM anytime via computer or any mobile devices. By adopting the PMOM in OT service, it helps to automate procedures for enhanced clinical accuracy and results, decreases time spent on integration of assessment scores and clinical record duplication and transportation.
Objectives :
1. To evaluate the effectiveness of electronic documentation system PMOM on decreasing time use on documentation and clinical handover 2. To reduce human error in clinical recording 3. To enhance individualized patient’s progress monitoring
Methodology :
In-service training was conducted & PMOM operation manual was prepared for all involved occupational therapists and supporting staff. After commencement, staff subjectively reported enhanced work efficiency & accuracy. Comparison of time use for documentation and clinical handover between PMOM system and traditional paper-based method was done in 3 areas: (1) patient-administered assessments, (2) staff-administered assessments and (3) clinical reporting in the Clinical Management System. Standardized work assessment VALPAR Component Work Sample; Recovery-orientated assessments and reports were selected as analyzed samples, their operating procedure and time spent on administration by traditional method and PMOM were recorded respectively for evaluation of the effectiveness of PMOM.
Result & Outcome :
Results showed that overall time use on documentation after adopting PMOM decreased in standardized assessments record and clinical reporting by 47% and 86% respectively. PMOM has pre-set formula in all assessments; assessments score would integrate automatically in pre-set reports templates. Therefore, human error in calculating the score can be eliminated. For clinical handover, staff can easily access to PMOM for assessments and reports at any time and in anywhere. Therefore, the newly launched PMOM system is useful to promote effective documentation and clinical handover.
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