Background We have had an electronic patient record (SystmOne) at the hospice for the past five years. This is our tool for documenting the care that we provide, viewing and reviewing these notes and reporting on this data. Our patients and families have input from many members of the multi-disciplinary team to ensure that they receive person-centred holistic care. Our electronic patient record, SystmOne was structured so each discipline completed initial assessments within a communal template but ongoing care tended to be written as separate reviews and action plans. The result of this was silos of information and staff not reading each others notes and using the information obtained from patients and families to the optimum. We recognised that the crucial bits of information from patients that make a huge difference to their experience were not being captured and communicated well.
Aims To put people at the centre of their care and support and maximise their involvement through development of person-centred templates on SystmOne.
Methods Multidisciplinary team meetings explored the current methods of documentation. Using patient journeys, a gold standard method of documentation was designed within SystmOne. Generic nursing care plans were removed and replaced with a multi-disciplinary ‘About me’ Care plan.
Results An ‘About me’ care plan pops up as soon as an electronic record is opened. It is completed by all members of the MDT and tells us how to care for a patient. It is divided into seven domains of care. It includes phrases like ‘Julie likes to have a Baileys in the early evening’. All other elements of care are documented in a person -centred care template by all disciplines.
Conclusions The new method of documentation puts the patient at the centre of their care and ensures their care and support is completely individualised.
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