Leading Change for Integrated Healthcare Records in a Mental Health

Assignment Task

Clinical Case Scenario

Happy Clinic, located in a large rural town in Western Australia, is a private mental health hospital with 50 beds. It runs a 3-week program where patients attend psychotherapy groups, have private psychology sessions and also a weekly review with a psychiatrist. The clinic is staffed by registered and enrolled nurses, a psychologist, a social worker, two psychiatrists, and kitchen, cleaning and administrative staff. A Director of Nursing, a Deputy Director of nursing and a business manager oversee the operations of the facility. 

The clinic is about to undergo accreditation, and the Director of Nursing (DON) was asked to improve the documentation in the facility. The facility uses paper notes only, and the DON found that the nursing notes were very simplistic and contained minimal information. Some nurses had even written the same note daily. The DON also found that there were several different folders used: one for care plans, one for medication, one for medical notes, one for physical observations, one for nursing notes, and one for allied health. This lack of integration was identified as creating a risk to safety and quality. Clinicians were not looking at each other’s notes, meaning that care is not holistic, and changes in mental health could go undetected. Therefore, clinicians rely on verbal handovers to understand the client’s health status and progress. The Director of Nursing asked you to lead the change to implement an integrated record.

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