Improving Clinical Documentation in Paediatrics

Background: Medical records are a crucial aspect of a patient’s journey. It provides the clinician with a permanent record of the patient’s illness and ongoing medical care, enabling informed clinical decisions.

In many hospitals, patient medical records are written on paper. However, written notes are liable to misinterpretation due to illegibility and misplacement. This can affect the patient’s medical care and its medico-legal robustness. Electronic patient records (EPR) have been gradually introduced to replace patients’ paper notes, with the aim of providing a more reliable record-keeping system. EPR have also been shown to improve the quality and efficiency of patient care.

The Paediatric department of Queens Hospital Burton utilizes a mix of paper notes and computerized medical records. Clinicians primarily use paper notes for admissions, wardrounds, and clinics. Laboratory tests, imaging results, and prescription requests are executed via the EPR system. Documentation by nurses is also carried out electronically.

Objective: Improve and standardize clinical documentation of paediatric admissions and wardround notes.

Methods: We developed an electronic admissions proforma for initial paediatric assessments and wardrounds.

We undertook a staff survey investigating sentiments about the written and electronic notes, before and after implementing the electronic notes. Doctors, nurses, healthcare support workers, and medical students were surveyed about the quality, utility, and usability of the electronic records. The completeness of specific fields was also recorded.

Conclusion: This quality improvement project aims to improve clinical documentation on the Paediatric ward. We seek to enhance patient record-keeping, improve clinical information-sharing, and streamline the patient journey.