368 Challenges Moving to a Fully Electronic System: An Audit

Abstract

In October 2020, our hospital moved to an all-online clinical record keeping system, resulting in clinicians becoming responsible for electronically requesting follow up appointments at the time of each clinical encounter. We aimed to ensure that with the introduction of the new computing system, appropriate follow up was booked and all members of staff were proficient in utilising this new system.Operative notes were reviewed to obtain the requirements for follow up, specifically for wound assessment clinic (WAC), hand therapy (HT) and outpatient clinic (OPC). Patient charts were then reviewed to ascertain if planned follow up happened, was booked, or was requested. We re-audited this 4 months later, following departmental education.In the first week of using the new electronic system, 100% of required WAC (24/24) and HT (13/13) follow up appointments were completed, however 14% (4/27) of required OPC appointments had not been requested.Following departmental education, the re-audit found similar results, however the 12% (4/31) of cases where OPC follow up was not requested, it was not specified in the operation note whether or not this was required.When introducing new clinical systems there is potential for unfamiliarity with use to impact on patient care, even after trust-wide training. It is important to bear this in mind and continue to audit and educate staff, implementing appropriate safety netting systems. Detailing the follow up plan in operation notes, including when follow up is not required, improves communication between staff and ensures required follow up is not lost.