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To improve documentation and resulting quality improvement, we recommend the revision of the neonatology patient chart and onsite training/supervision.
We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications.
This study aimed to implement a multidisciplinary quality improvement project in Perth Royal Infirmary A&E department to improve documentation of visual acuity (VA) in patients presenting with ocular injury.
Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care.
In addition, we have evaluated the categories of MDT decisions that have not been documented to highlight which areas are most frequently overlooked to help improve documentation accuracy in the future.
The aim of this study is to test the clinical reliability of the PACT and evaluate whether the use of PACT will (1) enhance the recognition and response to patients at risk of deterioration in PACU; (2) improve documentation for handover from PACU nurse to ward nurse; (3) result in improved patient outcomes and (4) reduce healthcare costs.
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Therefore, this category is divided into organizational improvements (e.g., improved documentation or process automation) and medical improvements.
This is all minimally documented; we are working on improving documentation, but users of this software are encouraged to add documentation to these wiki pages.
In a separate performance improvement project, however, we had markedly improved documentation of aspirin and beta-blocker use in chest pain patients using a CDSS with a single reminder phrase just above the "ENTER" button of a given HPI template.
A strategy involving simple structural improvements, in-service training opportunities, effective team-based mentoring, and improved documentation has the potential to strengthen the capacity of the providers to care for vulnerable newborn babies.
Results: The Emergency Department Expert Charting System improved documentation rates for all modules.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com