A new chapter! A new experience!

My first day on the wards since making the decision to give the NHS my commitment to help improve services with many years nursing experience under my belt.

Working in a busy Trauma and Orthopaedic ward in an acute setting brings it’s own challenges with an ageing population and osteoporosis affecting over three million people in the UK we are seeing more patients admitted with complex co-morbidities with primary care requirements on discharge.

The initial contact with a patient on admission is crucial in building rapport in a strange environment in which people put trust in those caring for them. This makes it all more important that the information captured at this point is accurate and the information available to health care professionals is at hand to make decision making in the onward care of the population.

A typical scenario that has become common place in my last few weeks working in the NHS is the lack of case notes on admission and disparate information which is poorly captured, badly written and mostly eligible for the majority of time. As a health care professional it is my duty to use this information to gather history, assess my patient and plan their care whilst under our care.

The hospital has minimal use of technology to support this process, the only information that is captured on any system is the administrative admission details and observation recording all other clinical data capture is completed on paper of which there is a lot of!

By getting the basics right the complex requirements will follow on naturally. The fundamental idea of patient information being accessible to all is not a new one and should be the backbone for any EPR solution.

By supporting an admission minimum data set for both doctors and nursing staff including risk assessment, core care plans, clerking pro forma and evaluation notes would go a long way to improving patient flow and information accessibility.

Quoting the five year forward view ambitions for quality sums it up perfectly: the definition of quality in health care, enshrined in law, includes three key aspects: patient safety, clinical effectiveness and patient experience. A high quality health service exhibits all three.

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