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Paediatric 'paperless' clinical record

Paediatric 'paperless' clinical record

What is a 'paperless' clinical record?

This is a record of all clinical interactions with each patient that is held electronically.  Staff enter all information via a computer rather than writing on a paper record.


What are we trying to achieve?

Value: Better, Best, BrilliantWaitemata Home Care for Kids (WHC4K), the children’s community nursing team has been documenting most clinical notes electronically since 2006.  Paper codafiles (paper files) were still kept to store the original referral, assessment forms and other clinical information.  For short term (transitional) patients these codafiles often had only one or two pieces of clinical information.  This was inefficient and expensive.

Our aim was for all of WHC4K documentation to be electronic with no permanent (paper) clinical file kept for transitional patients.  This would ensure our Child Health Services are ready to implement the National Health IT Board plan for integrated health information at point-of-care.

What are the benefits of an electronic health record?

  • Aids collaborative care- multi-disciplinary team record
  • Clinical decision support
  • Documentation at point of care
  • Saves time
  • Integrated with inpatient services
  • Improved legibility
  • Improved response from practitioner at time of patient contact

What have we done?

Paperless change processChanges were made to the referral process, discharge process and discharge form.  Careful attention was paid to the nurse's natural work flow with an underlying philosophy that this should be easier not harder. 

Legal advice was obtained regarding the storage of the faxed referrals and staff training was held with a willing and receptive team.

Electronic child profile assessment
Electronic child profile assessment for WHC4K


Did we make a difference?

No permanent clinical files are kept for WHC4K transitional patients with a conservative estimated savings of $ 7,324.00 per year.  All nursing contacts and assessments are electronic.  We were unable to create an ‘offline short term assessment’.  Future challenges are to further develop the electronic referrals(e-referrals) system and provide online growth charts.

Before
Before

After
After

Conclusion:  It is possible to be paperless at Waitemata DHB


Where are we now?

  • Process implemented
  • No permanent file
  • Nurses and administration staff accept and embrace process
  • Planning next phase for HC4K
  • Roll out to Child Women & Family Services

Further local initiatives

  • Further development of electronic child profile
  • Establishment of Child Health I.T. development group
  • Development of a Child Health Information System strategy

Where to from here?

Best

We have achieved what we can with what we’ve got

Better

To be fully paperless
E-referrals, E-prescribing, Online growth charts, Online access to labs/ E.D.S at POC via tablet devices, access to clinical decision support

Brilliant

Seamless flow of patient information throughout the care continuum that integrates with primary health


Winner in "Excellence in research or technology" category at Waitemata Health Excellence Awards 2012