Wading through the paperwork: making complex patient notes easier to navigate

ABSTRACT

BackgroundBulky hand-written notes and frequent staff changeovers (due to on-call shift patterns) mean that details of plans for complex or long stay patients can be missed. Muddled verbal handovers are tiresome and things can be forgotten at the end of busy night shift. Wading through paper notes can be unnecessarily time consuming, making onward referral harder and slower, and mistakes more likely if the clinical problem is difficult to understand. Most paediatric patients are discharged before 7 days, so patients that stay longer than this are likely to have more complex medical needs. This project was conducted at a busy London DGH during the Covid-19 pandemic.ObjectivesThe overall objectives of the project are toReduce the amount of time wasted reading through paper notes to understand the clinical history.For all staff to be able to easily understand the clinical problem and execute the next steps of the management planReduce the potential for patient harm through missed clinical plansPrompt teams to consider differentials and alternative management options in challenging clinical scenariosMethodsRetrospective data was analysed to see the numbers of patients admitted for ≥7 days to get an idea of the scope of the problem. Diagnostic data was gathered using a fishbone diagram to explore the issues surrounding the problem. The Model for Improvement method was used to plan and execute the project. Various change ideas were considered as part of this project and a questionnaire was sent to junior doctors within the department to gauge current feelings about difficulties around making referrals for complex patients.ResultsOver an 8 week period, there were between 1–4 patients each week that fulfilled the criteria of admission ≥ 7 days, with the longest staying for 3 weeks. Each of these patients were discussed with at least one referral centre during their admission and several were diagnostically challenging.Paediatric juniors were surveyed to gather objective and subjective data on current practise. 13 people responded;69% had spent >10 minutes going through patient notes prior to making a referral. 75% felt they spent ‘considerable time’ going through patient notes to make a referral, 76% felt it took longer than necessary and 69% felt that despite this they had still missed important parts of the history.A weekly proforma was developed to summarise patient notes for anyone admitted for ≥7 days;this has been developed and improved through a series of Plan-Do-Study-Act cycles and will be introduced alongside restarting the weekly complex patient MDT meeting.ConclusionsInitial data indicates that there are enough patients admitted to the Paediatric ward for ≥7 days on a regular basis to merit an intervention. Feedback from colleagues indicates that navigating complex patient notes is a source of frustration and that there is a need to summarise them more effectively. Progress has been delayed due to the Covid-19 pandemic as the Paediatric ward was closed for several months. However now the ward has re-opened there is opportunity to move this project forward, and implement a positive change.