Quality Improvement
Documentation
There is a doctor who appears on all the wards at the RCH..........
He is promoting better documentation and is on posters around the hospital.
Dr Documentation encourages accurate, complete and legible documentation such as:
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Recording date and time against all entries in the medical record
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Signing all entries in full and including a printed name, designation and contact details
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Ensuring history and examination findings, an assessment and a plan is documented for each admission.
Regular documentation audits, which assess the quality of medical staff entries in progress notes, indicate the major areas requiring improvement are the documentation of contact details, designation and legibility/printing of name. Dr Documentation promotes 100 per cent compliance with all documentation criteria, as outlined in the posters in which he appears.
The Dos and Don’ts of Documentation
Do write
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Date and time of your entry
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Purpose of entry eg. admission note, planned review, asked to see patient, end of shift report
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History and examination findings – be succinct!
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Assessment of current situation
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Plan what needs to happen now and later
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Print name and sign
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Position, pager number/contact details
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Use the RCH Abbreviations List (PDF 50KB)
Don’t write
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A repeat of clinical details previously written – this wastes yours and other’s time
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Anything unpleasant, rude, or critical of either parents, patients or staff
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Don’t backdate entries or change existing entries
Policy
See the official RCH Policy - Documentation: Medical Records for details of your obligation to provide accurate, complete and legible documentation.
Any documentation questions can be directed to Kathy Cassin, Manager Health Information Services on extension 6106.
Continuous Quality Improvement Program
Health Information Services aims to achieve excellence in the quality and accessibility of patient and clinical information for the delivery of high quality patient care whilst minimising costs and protecting the confidentiality of patient data
To ensure that the highest quality of service is provided to staff and clients, HIS has a Continuous Quality Improvement Program in operation.
