Electronic Handover by Using a Structured eNursing Note Template

Introduction

Nursing documentation is one of the responsibilities of nurses to record clinical documentation promoting continuity of care and safe care. Accurate nursing record is an important factor to facilitate clinical handover and communication of patient information. In previous practice, Handover Sheet was used to record patient information and progress for clinical handover. However, the design appeared incomprehensive. Retrieval of patient information was difficult due to multiple pages without eye-catching remarks. Additionally, physical storage of Handover Sheets was limited and shredding was required for disposal. In view of the corporate direction of building digital workplace and the limitations of the Handover Sheet, an initiative was formed to develop an electronic Nursing Note Template for nursing documentation facilitating electronic based handover. Considering the benefits of the electronic nursing note template, it ensures secure access via Clinical Management System (CMS), turns paper documents into digital files and goes paperless. It markedly helps for efficient search of patient information of standard format facilitating effective handover in a consistent delivery of patient information and enhancing patient information communication between shifts and between health care professionals. More importantly, it retrieves patient information in a timely manner as access is possible everywhere when CMS device is provided.

Objectives

To change nurses’ behaviours by using a structured electronic nursing note template to conduct electronic handover.

Methodology

1. To design a structured electronic nursing note template for nursing documentation. 2. To conduct few meetings in order to explain and clarify any problems and to reach consensus. 3. To develop and introduce an instruction manual on use of electronic nursing note template. 4. To observe the change of the way of using electronic nursing note for handover.

Results & Outcome

The evaluation showed the process was successful. Most of the nurses accepted the change of handover practice. Compliance to using electronic handover was 100%. Effective handover in a consistent manner was achieved. This change is a close match with the current work activities promoting operational efficiency. Apart from this, patient information communication between shifts and between health care professionals was enhanced.