If we want to move away from a paper record then we have to make sure the basics are supported in whatever IT solution we are going to adopt and that the information we are entering is presented in a meaningful way that helps us in our daily routine when caring for our patients.
This doesn’t mean taking the paper record and making it electronic! It means using the technology available to us to enhance the display of information and let the user know by means of visual aids that a patient is deteriorating, needs a task competing or is fit for discharge.
The nursing handover information is a key area where this can make all the difference by utilising IT to it’s full potential surfacing the relevant clinical information that has been recorded throughout the patient journey in a manner that allows continuation of care in a structured way. By allowing clinicians to select the displayed information to drill down into a more detailed view enables a more thorough handover if required depending on the patients acuity.
Nurses should be able to see Diagnosis, NEWS, Risk Assessment Scores, Acuity, multidisciplinary team outcomes and outstanding actions without having to search through paper records to find the information if it hasn’t been entered or updated on a paper handover. Many who rely on these pieces of paper, including myself at times, find themselves in dire straits if it is mislaid or lost by pulling a roll of tape or scissors out of your pocket as we think it is the only means of communication at that crucial point of handover.
The safest way to support handover whether it is for an individual patient to another ward, doctor to doctor or shift change is by supporting this via an EPR with mobile technology. A long way off for some health organisations but something that should be on the roadmap as a priority for most.