Quality & Safety
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Communicating for Safety Clinical Documentation Audit
The Clinical Documentation audit was undertaken in May–-June 2025. Overall, Allied Health achieved 95% and Nursing achieved 82%. Things we can do better: Check and document 3 points of patient identification at initial encounter and at handover Introduce oncoming staff (at handover) Complete the Adult Risk Screen Pathway within 8 hours of the patient's admission to the ward AND action the treatment options Health Information Services also completed a clinical documentation audit for the same period with Ryde Hospital achieving 78%. The top three criteria which need to be addressed were: Does all electronic documentation consist of approved medical terminology and abbreviations (as per NSLHD Abbreviations Policy)?- 0% achieved The most common UNAPPROVED abbreviation used is TOC (transfer of care). Please refer to the Abbreviations, Acronyms and Symbols intranet page for information regarding Have the appropriate document types been used for the purpose of the entry?-36% achieved Ensure the correct note type is selected in eMR prior to verifying documentation. The majority of errors related to using a “Progress Note” as opposed to “Progress Note– specific designation”
Have all records been signed and verified? 66% achieved Ensure verification is completed by checking document audit trail before signing out
Single Digital Patient Record – coming to NSLHD in 2026 The Single Digital Patient Record (SDPR) is a state-wide program that will give clinicians real-time access to a patient’s complete health information - all in one secure, easy-to-use system. No more jumping between platforms or chasing records from other districts. Whether you're working in a hospital, community health setting, or on the move, SDPR will provide real-time, holistic patient information, s implified workflows with intuitive design and mobile access, and enhanced clinical safety with less duplication.
Early planning works have commenced in preparation for SDPR to be implemented within NSLHD and Ryde Hospital in late 2026, with an anticipated go live date in November 2026.
Further information is available HERE (or scan the QR Code).
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