Review of dietetic documentation and clinical handover processes at Peninsula Health

Ms Alice Goodman1, Ms Karen Edis1

1Peninsula Health , Frankston, Australia

Aim: To streamline documentation and clinical handover processes for dietitian.

Method: A Clinicians in Redesign project obtained feedback from Allied Health (AH), Medical and Nursing staff regarding current AH documentation processes. Issues identified included duplication, over documentation, excessive time spent documenting and variable approaches to clinical handover. In response, a working group was formed to undertake a review of dietetic documentation and clinical handover practices. A collaborative approach was utilised to create new processes which were ‘product tested’ by dietitians over a trial period.  At its conclusion, feedback informed finalisation of a guideline and templates for these new processes.

Results: A new Documentation Clinical Practice Guideline, revised formats for initial assessment and review ‘entries’, and a new clinical handover template were developed. There was a shift away from the traditional approach to documentation, particularly in relation to the content and frequency of ‘entries’ while ensuring adherence to professional and organisational requirements. Practical examples of completed templates and file ‘entries’ were included in the guideline to assist staff in transitioning to the new process. A documentation audit tool was developed and embedded into Performance Development Review and clinical supervision sessions as a means of providing feedback and monitoring compliance to the new processes.

Significance of the findings to allied health: Implementation of new documentation and clinical handover processes will enable PH dietitians to have a more efficient and consistent approach to documentation. This review process and associated outcomes could be rolled out across other AH disciplines to achieve similar results.