Authors: (including presenting author): :
Ho C Y (1) Kwok P H (1)
Affiliation: :
(1) Occupational Therapy Department, Pok Oi Hospital
Keyword 1: :
E-documentation
Keyword 2: :
AI-assisted audit
Introduction: :
With the implementation of electronic documentation (e-documentation) in the Hospital Authority (HA) hospitals, maintaining high standards of quality and safety in Occupational Therapy (OT) clinical records has become essential. Traditionally, documentation audits required peer reviews by colleagues from other hospitals to ensure objectivity and impartiality. However, this approach was resource-intensive, involving significant manpower and time, which limited the number of cases that could be thoroughly audited. This project introduces the use of Artificial Intelligence, specifically HAgenAI tools, as an innovative alternative for conducting documentation audits. By supplementing manual Clinical Management System (CMS) checks with HAgenAI analysis, the initiative aims to enhance audit efficiency while preserving — and even surpassing — objectivity, allowing for more comprehensive quality assurance in OT e-documentation.
Objectives: :
The primary objectives of this audit project are: To evaluate compliance with established OT documentation standards in in-patient e-records using a combination of CMS checking and HAgenAI analysis. To demonstrate the feasibility and effectiveness of AI-assisted auditing as a scalable replacement for traditional peer audits. To highlight the superior advantages of HAgenAI in overcoming the limitations of human-led audits, thereby improving quality control processes for OT services.
Methodology: :
The audit focused on in-patient OT e-documentation during the period from 1st November 2025 to 30th November 2025. Cases reviewed included in-patients admitted on or after 1st November 2025 and discharged by the end of November 2025, who received OT services. A total of 40 cases were randomly selected by case number, with 10 cases from each of the following specialties: Orthopedics & Traumatology (O&T), Surgery (SUR), Emergency Medicine (EM), and Medicine & Geriatric (M&G). The audit employed a hybrid method: direct CMS checking supplemented by advanced HAgenAI analysis for thorough evaluation against 12 predefined criteria: Each entry is dated correctly (aligned with OT attendance). Referral source documented (date and source, if relevant). Reason for referral documented (diagnosis/problem or scope of service). Clinical information documented (e.g., operation history, other diagnoses). Assessment documented (observations, findings, and scoring). Problem/goal/objective identified. OT intervention documented (treatment/service provided). Progress documented (changes post-intervention, if any). OT management plan documented (initial/ongoing plan, discharge summary). Legibility (no unreadable words in e-documentation). Correct/appropriate abbreviations or symbols (consistent with approved lists). Each entry is signed. HAgenAI prevails over traditional human audits in several key ways: Superior efficiency and scalability: HAgenAI processes vast volumes of records rapidly, enabling audits of significantly more cases without additional manpower, reducing audit time from days to minutes. Enhanced consistency and objectivity: Applies uniform criteria without human variability, fatigue, or subjective bias, ensuring identical standards across all reviews. Reduced human error and greater accuracy: Detects subtle inconsistencies, omissions, or patterns that humans might overlook due to oversight or fatigue. Cost-effectiveness: Minimizes resource demands, such as inter-hospital coordination and staff time, allowing clinicians to focus on patient care. Real-time capabilities and continuous monitoring: Supports ongoing or more frequent audits for proactive quality improvement, unlike periodic human reviews. Data-driven insights: Identifies trends and anomalies across datasets, providing deeper analytical value beyond basic compliance checks.
Result & Outcome: :
The audit of the 40 selected in-patient cases revealed exceptional compliance with OT documentation standards. Through combined CMS checking and HAgenAI analysis, 100% fulfillment of all 12 audit criteria was observed across all reviewed cases, including the 10 cases from each specialty (O&T, SUR, EM, and M&G). This outstanding result underscores the high quality of current OT e-documentation practices. The successful integration of HAgenAI demonstrated its superior reliability and efficiency as an audit tool, confirming its potential to fully replace resource-intensive human audits while enhancing objectivity, accuracy, and thoroughness. Future expansions could involve larger sample sizes, real-time monitoring, or broader application across HA services to sustain and elevate quality assurance in OT and beyond.
