Charting

Christine JerrettImagine being able to hand over client cases at the end of a shift, knowing that all the information is at your fingertips. “It’s all right there – one source of truth,” says Christine Jerrett, Clinical Informatics Lead, Critical Care for CST.

When the new clinical information system is in place, clinical staff will use electronic clinical documentation, or charting, to record a patient's status and problems at the point of care, and to communicate these to other care providers.

“Electronic documentation helps with standardization and accessibility,” explains Christine. “For example, right now, if a physiotherapist documents a note about a patient’s pain, it’s in a separate section of the chart from other notes, where nurses and other care providers may not see it. The clinical documentation team is striving to facilitate interdisciplinary documentation, so that health care providers can share information, and it isn’t housed in siloes – it’s readily visible to all clinicians.”

With standardized electronic documentation, care providers can easily find, filter and organize clinical information and quickly share it with patients and each other, especially because more than one person will be able to access the chart at the same time.

This makes patient education and follow-up easier and more effective. There is less duplication of effort in creating forms, recording results, and creating care plans; which means more consistency. By using standardized electronic templates and menus, clinicians can be confident that they have entered all necessary patient information.

It’s important to get this right at the beginning. That’s why multi-disciplinary teams of health care professionals from across VCH, PHSA and PHC are working to design evidence-based workflows and tools.

As Christine says, “Patients deserve to know they’re getting the same level of care wherever they are, that it’s always based on leading practices, down to the level of what clinicians are assessing and the information they’re communicating to other members of the care team.”

Download a printable version of the article Information at your fingertips (PDF).

Find out more about the Clinical Documentation design/configuration team.