Authors (including presenting author) :
Fok PA(1), Kwan SM (1), Chu LS(1), Chan CW(1)
Affiliation :
(1) Department of Family Medicine and Primary Health Care, Kowloon West Cluster
Introduction :
Good consultation notes can facilitate communication between care providers and provide clear and succinct documentation. However, there is no consensus as to how clinical information should be being laid out. Most consultation notes audit only focus on the components of consultation. Lengthy notes with redundant or outdated information cause frustration and difficulty in following up the patients as well as requiring prolonged time to read the notes. This eventually can affect morale of doctors.
Objectives :
To identify areas for improvement in documentation that can facilitate consultations. To explore on advantages of modified consultation notes. To understand the difficulties encountered in improving clinical documentation among family medicine trainees.
Methodology :
Questionnaires with 9 questions on comparison of pre and post modified notes were distributed to community based trainees.
Result & Outcome :
15 community based trainees completed the questionnaire with the response rate of 100%. 15/15 (100%) agreed the modified notes save consultation time. 11/15 (73%) agreed the modified notes will not lead to missing important past history. 12/15 (80%) agreed inputting the drug alert can reduce risk of prescribing medication with adverse reaction. 12/15 (80%) agreed modified notes can reflect more accurate chronic diseases diagnosis. 14/15 (93%) agreed the modified notes can facilitate other colleagues to manage the case at next visit. 7/15 (46%) felt the updated notes are easier to read. Colleagues do have concern about updating the notes, 6/15 (40%) expressed difficulties in choosing relevant past history to be retained; 2/15 (13%) concerned about the time needed to update the notes. Most respondents agreed that modified consultation notes not only helps by saving consultation time; it reduces medication incidents and facilitates patient management. However there are difficulties encountered in modifying consultation notes e.g. demanding extra time/uncertainty on which part should be kept. In order to proceed, modification of notes can be divided into 5 aspects including simplifying past medical history, inputting drug alert in relevant boxes, clearing outdated investigation results, simplifying drug modification history, inputting social history in summary page. Doctors can update 1-2 aspects in each consultation accordingly until all aspects are addressed. Case demonstration with notes with complicated past medical history notes can be illustrated in order to have a consensus on how it should be modified. Ultimately, we hope that a more precise and concise consultation documentation can lead to a more effective use of consultation time and better patient management, resulting in less frustration and better staff morale.
Co-location with:
