.
Background
Hospital background:
a. Acute care hospital
b. Departments: ER, Maternity, Medicine, Surgery, Psychiatry, ICU, Palliative Care and Renal Dialysis
Problem
Inpatients are often transferred between hospital nursing units e.g. Medicine to Palliative Care, Surgery to Medicine (due to co-morbidities), or ICU to Medicine, etc. At this particular hospital, when a patient was transferred between units, there was confusion because each unit had individual preferences regarding how information was organized in the chart. Each unit used a binder with the same dividers on the chart but information was filed inconsistently throughout the hospital. For example, some units had a special divider for diabetic orders while others filed diabetic orders with physician orders. In some units, consultation notes were filed in the “consult” section while other units filed consultation notes under the “progress notes” section. Personal Directives and DNR orders were found in different places as well. When a patient was transferred from one unit to another, chart notes were removed from the binder of the sending unit, taken to the receiving unit where the unit clerk arranged the notes according to the preference of that unit. Health care providers experienced frustrations and wasted valuable time as they tried to learn the “ways” of each unit when accessing and recording patient information and when trying to find information during an emergency. The staff in medical records spent hours taking apart chart notes when patients were discharged and had to file them in yet another order in the Health Records Department.
Proposed Change
The hospital proposed the following solution: remove all the old binders. Establish a new “chart order” outlining how patient information would be filed in the chart, including the order of filing within each divider. When a patient is transferred between units, the binder would follow the patient. The unit clerk in the receiving unit would hand over an empty binder to be taken over to the sending unit.
Benefits (desired state)
Unit clerks will have more time to concentrate on other tasks, health care providers know where to access and record information on the chart and the staff in medical records spends less time organizing the documentation when patients were discharged. It would also be easier to access pertinent information during a medical emergency.
Hospital background:
a. Acute care hospital
b. Departments: ER, Maternity, Medicine, Surgery, Psychiatry, ICU, Palliative Care and Renal Dialysis
Problem
Inpatients are often transferred between hospital nursing units e.g. Medicine to Palliative Care, Surgery to Medicine (due to co-morbidities), or ICU to Medicine, etc. At this particular hospital, when a patient was transferred between units, there was confusion because each unit had individual preferences regarding how information was organized in the chart. Each unit used a binder with the same dividers on the chart but information was filed inconsistently throughout the hospital. For example, some units had a special divider for diabetic orders while others filed diabetic orders with physician orders. In some units, consultation notes were filed in the “consult” section while other units filed consultation notes under the “progress notes” section. Personal Directives and DNR orders were found in different places as well. When a patient was transferred from one unit to another, chart notes were removed from the binder of the sending unit, taken to the receiving unit where the unit clerk arranged the notes according to the preference of that unit. Health care providers experienced frustrations and wasted valuable time as they tried to learn the “ways” of each unit when accessing and recording patient information and when trying to find information during an emergency. The staff in medical records spent hours taking apart chart notes when patients were discharged and had to file them in yet another order in the Health Records Department.
Proposed Change
The hospital proposed the following solution: remove all the old binders. Establish a new “chart order” outlining how patient information would be filed in the chart, including the order of filing within each divider. When a patient is transferred between units, the binder would follow the patient. The unit clerk in the receiving unit would hand over an empty binder to be taken over to the sending unit.
Benefits (desired state)
Unit clerks will have more time to concentrate on other tasks, health care providers know where to access and record information on the chart and the staff in medical records spends less time organizing the documentation when patients were discharged. It would also be easier to access pertinent information during a medical emergency.
