Unsigned Documentation As we approach our upcoming hospital accreditation, it is crucial that all allied health, nursing, and medical teams ensure that all documentation is completed and signed off. Ensuring our documentation is up to date not only improves patient outcomes but also demonstrates our commitment to maintaining the highest standards of care.Specifically, we need to address the following areas: 1. Unsigned PowerNotes and PowerCharts: • Our latest reports indicate there are still several unsigned documents across departments. For example, in 2024 up to end of August, there were 632 unsigned Nursing PowerNotes, 2451 unsigned Medical PowerNotes, and 11 unsigned Allied Health PowerNote. • It is vital that these documents are reviewed and signed to ensure compliance with the communicating for patient’s safety standards. 2. Outstanding Discharge Referrals: • We have noted a steady increase of number of outstanding discharge referrals, up to end of Aug, with 213 referrals remaining unsigned in 2024. • Please make it a priority to complete these as they directly impact patient continuity of care. Hospital Information Service (HIS) thank you for your attention to this matter. Let’s work together to ensure we are fully prepared.
Multilingual Medication List Patients receive information about their medications in the eMR Discharge referral paperwork. However, the Pharmacy dept is able to produce a patient friendly medication list printed from the pharmacy dispensing program. This contains detailed information about when and how to take medications as well as indications for use and any cautionary advisory warnings. As part of a quality improvement initiative to support our culturally and linguistically diverse (CALD) patients, the medication list is now multilingual and available in 4 languages other than English; Chinese (simplified and traditional), Korean, Japanese, and Italian. This was a local initiative from the pharmacists working within the NSLHD Digital Health Service to improve the level of support we provide our CALD patients.
The patient friendly medication list is often recommended for patients taking multiple medications, medications with complex instructions, patients with multiple changes to their pre-admission medication regimen or to aid medication adherence. The provision of a medication list (also known as a Medilist) is recorded in the Pharmacy Discharge Review eMR document in the section “Medication supply and education.” Any clinician can recommend the provision of this tailored medication list by contacting the ward pharmacists. The pharmacists make an assessment regarding the information needs of the patient as part of their Medication Reconciliation on Admission eMR document and document this in the section “Pharmacy Discharge Plan.”
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