Authors: (including presenting author): :
Ho KWE, Wong CL, Tsang WY
Affiliation: :
Ward P2DM, United Christian Hospital
Keyword 3: :
Communication
Keyword 4: :
Quality of Care
Keyword 5: :
Standard of Care
Introduction: :
Nursing documentation, particularly in Kardex systems, is a cornerstone of daily clinical practice in acute medical wards. Accurate, guideline-driven documentation upholds care standards, enhances inter-professional communication, and supports incident traceability. However, high patient turnover often leads to inconsistencies, risking patient safety and care continuity.
To address this, our quality improvement initiative introduced several 50x100mm-sized standardized labels to promote uniform documentation among nurses. These tools target critical elements during admissions and transfers, reducing errors and improving communication. Additionally, this facilitates the transition to electronic documentation (eDoc) by informing standardized nursing templates, fostering consistency and supporting digital transformation in healthcare.
Objectives: :
1.Ensuring nurses have precise documentation in the nursing Kardex
2.Maintaining patient safety and care quality
Methodology: :
This quality improvement project was conducted in an acute medical ward to standardize nursing documentation during patient admissions and transfers, with a focus on enhancing patient safety and effective communication. A nursing team developed four targeted labels.
The intervention involved designing and implementing the following standardized tools:
1.Admission Checklist Label: A mandatory input affixed to patient charts upon transfer-in, requiring nurses to document baseline skin condition (e.g., intact, wounds, or pressure risks), presence of dentures, inventory of personal properties (e.g., glasses, jewelry), and confirmation of relatives informed via phone or in-person. This ensured comprehensive initial assessments and facilitated inter-shift handovers.
2.Denture Documentation Label for Transfer-Out: A detailed sticker specifying denture type (upper/lower jaw), storage method (e.g., in labeled box or with luggage), and condition, to prevent loss during transitions and promote accountability in patient belongings management.
3.Self-Financed Drugs Inventory Label: An admission-specific tag listing patient-owned medications by name, quantity, and expiry, integrated into medication reconciliation processes to avoid duplication errors and support safe integration with ward supplies.
4.Pre-Transfer Vital Signs Label: A required pre-departure form capturing blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature, with timestamps, to assess transfer readiness and provide receiving facilities with critical data for seamless care continuity.
Tools were created using simple, adhesive label formats with a size 50x100mm. Nurses can easily stick in on Kardex and ensure standardized nursing documentation.
Result & Outcome: :
Documentation compliance reached 100%, with all targeted elements—skin condition, personal belongings, denture details, self-financed medications, family notifications, and pre-transfer vital signs—accurately recorded without omissions. Incident reports related to lost items or documentation-related errors dropped to zero. Staff satisfaction surveys revealed 100% positive feedback, with nurses reporting enhanced confidence, reduced workload stress, improved communication during handovers, and strong support for the tools' role in standardizing care.
Importantly, these labels serve as an effective prototype for the upcoming electronic documentation (eDoc) transformation. By establishing uniform prompts and formats, they ensure that all nurses share identical templates, promoting the most precise and comprehensive recording of critical patient information.
This standardization directly enhances patient safety through reduced omissions and errors, while upholding consistent standards of care across shifts and teams. For the transition to eDoc, incorporating these proven label structures into digital templates will facilitate seamless adoption, minimize variation, and sustain long-term improvements in documentation quality and interprofessional communication.
