EFFECTIVE DOCUMENTATION AND COMMUNICATION
It is clear that good communication lies at the heart of good practice and thus promotes patient safety. Many errors have been demonstrated to arise from the lack of adequate or accurate communication. There is a great deal of support for the development of effective documentation and communication in the provision of safe patient care.
Documenting to Prevent Errors
Documentation is a tool for the planning and provision of patient care; communication among providers; and demonstration of compliance with federal, state, and local law, third-party payer, facility policy and procedures, as well as other regulations. Documentation should be consistent with the treatment plan(s) and meet all applicable professional and ethical guidelines. Documentation should also reflect established coding and billing procedures.
Guidelines for documenting include:
- Document in the correct chart. Check to make sure that key patient identifiers are accurate, including the spelling of the person’s name and date of birth, to ensure effective linking of patient healthcare information records within and across systems.
- Date and sign all entries.
- Document legibly.
- After making an observation or providing care, document actions for more detailed notes. Waiting to the end of the work shift can result in forgetting to include significant information.
- Be accurate, objective, and complete. Document what is seen, heard, and done. Include data relating to all aspects of patient care.
- Track test results and consultation reports to ensure that findings are properly communicated and acknowledged, and document these actions in the patient’s medical record.
- Use approved abbreviations. Unfamiliar or seldom-used abbreviations can confuse other providers and lead to potential patient injuries. Consult the facility’s list of approved abbreviations and use them consistently.
- Include patient communication. Document patient education regarding treatment and any educational materials, resources, or references provided to the patient.
- Document patient complaints, questions, and other concerns as well as steps taken to resolve concerns.
- Record instances of nonadherence. This may include missed and canceled appointments, refusal to provide information, and rejection of treatment recommendations.
- Document delegated tasks. Include verification that delegated patient care-related tasks are completed by those under one’s direction and/or supervision.
- Document discharge planning throughout episodes of care.
- Demonstrate skilled care and medical necessity.
- Correct errors promptly. Correct charting errors in accordance with the facility’s policies and procedures, ensuring they are clearly marked as late entries.
- When using documentation software for electronic entry of data, ensure that programs comply with appropriate provisions for security and confidentiality.
(Reiner, 2021; Sullivan et al., 2019)
Communication Tools to Prevent Errors
Research indicates that poor communication is a root cause of the great majority of all sentinel events.
RISK FACTORS FOR POOR COMMUNICATION
Verbal communication is a common source of medical error. Risk factors for such errors include:
- Disruptive behavior, rudeness, or verbal abuse
- Environmental noise issues
- Cultural differences between patients and providers
- Hierarchy issues
- Providers acting as autonomous agents
- Personality differences
- Language barriers
- Failure to work as a team
- Multiple conversations occurring at the same time
- Education and literacy
(HIPAA Journal, 2021)
TOOLS FOR EFFECTIVE COMMUNICATION
Communication among healthcare providers using a standard framework and proven tools for reporting and sharing information can enable more effective communication. Examples of such tools include:
- SBAR (see below)
- BATHE protocol (Background, Affect, Trouble, Handling, and Empathy) is an interviewing process utilized in outpatient settings to connect with patients, screen for mental health problems, and empower patients to handle identified issues more constructively.
- Ticket-to-Ride for handoffs is a short, in-house document ensuring that transporters and providers unfamiliar with the patient will have important information readily available if problems arise or the patient is away from the unit longer than expected.
- Hourly rounding to each patient’s room or bedside is an intervention that helps to proactively anticipate and address each patient’s needs.
- Patient teach-back is a technique for healthcare providers to ensure that medical information has been explained clearly so that patients and families understand the information given to them.
- I-PASS is a clinical handoff verbal and written protocol for patient in-house transfer that includes Patient summary, Action to-do list, Situation awareness and contingency plan, and Synthesis or Summary of the information by the receiver.
- Technological communication tools:
- Bedside tablets for patients instead of call lights
- HIPAA-compliant text messaging platforms for communicating among members of the care team
(HIPAA Journal, 2021)
SBAR
SBAR is one of the most common communication tools used for structured communication to ensure that information is transferred accurately between two clinicians, such as during a shift transfer. SBAR stands for Situation (S), Background (B), Assessment (A), and Recommendation (R). It uses prompt questions in four areas to guide a conversation to ensure efficient transfer of concise information (IHI, 2021).
(IHI, 2021a) | ||
S | Situation | What is happening right now? |
---|---|---|
B | Background | What are the circumstances that led up to this situation? |
A | Assessment | What do I think the problem is with this patient? |
R | Recommendation | What should be done to correct the situation? |
Speak Up
Well-informed patients are better able to avoid serious medical errors. Clinicians should follow protocols that guide care, health education, and communication to help in both their own and their patients’ decision-making about appropriate healthcare.
The Joint Commission encourages patient participation through their Speak Up initiative that encourages hospitals to inform patients about the importance of their contributions to the care they receive, making them active participants in avoiding medical errors (Rodziewicz et al., 2021).
(TJC, 2021b) | |
S | Speak up if you have questions or concerns. |
---|---|
P | Pay attention to badges worn by healthcare staff and remind staff to wash their hands. |
E | Educate yourself about your illness, medical tests, and treatment plan. |
A | Ask a trusted family member or friend to be your advocate. |
K | Know what medicines you take and why you take them. |
U | Use a hospital, clinic, surgery center, or other facility that meets standards of care. |
P | Participate in all decisions about your treatment; you are the center of the healthcare team. |