DEVELOPING 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 form of communication. It must be credible and timely and must accurately reflect the patient’s condition as well as the actions taken in response to that condition. Healthcare professionals must learn and follow their facility’s policies and procedures about documenting care.

COMMON DOCUMENTATION MISTAKES

Common documentation mistakes in patient records that can lead to errors in treatment include:

• Failing to record pertinent health or drug information
• Failing to record relevant details of a patient’s treatment, especially when treating multiple patients and across shifts
• Failing to record that medications have been administered, including dose, route, and time
• Recording in the wrong patient’s record (e.g., patients with similar names, similar conditions, physical proximity, or having the same attending physician)
• Failing to document discontinuation of medication
• Failing to record drug reactions or changes in a patient’s condition
• Transcribing orders improperly or transcribing improper orders

Illegible writing and poor transfer of information (both within a department and when a patient is transferred to another department or facility) can also cause medical errors (NSO, 2020).

ELEMENTS OF PROPER DOCUMENTATION

Documentation in the patient’s health information record should include, but not be limited to:

• Allergies (marked conspicuously)
• Current and past medications (prescribed, over-the-counter, holistic/alternative remedies) and adherence to prescribed regimen
• Medications administered and description of the patient’s response
• Risk assessment findings, including:
  • Ambulation status
  • Bowel and bladder function
  • Mental status
  • Elopement risk
  • Fall risk
  • Nutritional status
  • Pain management
  • Skin and wound condition
• Discussions with the patient about medical issues requiring additional explanation by another healthcare provider
• Professional observations during patient contacts
• Encounters with other healthcare providers, including those via telephone, facsimile, and email, with summary of discussion and subsequent actions taken
• Actions taken to contact healthcare provider to report abnormal test results and any provider orders for additional testing or follow-up of tests ordered
  (NSO, 2020)

To help prevent medical errors, the following documentation (charting) do’s and don’t’s are recommended:

Do’s

• Before entering anything, ensure the correct chart is being used.
• Document often and include all pertinent details.
• Always provide complete descriptions.
• Document medication administration time, the route, and the patient response.
• Document precautions or preventative measures used, such as bed rails.
• Record any phone call to a provider, including the exact time, message, and response.
• If a patient refuses to allow treatment or take a medication, document it and be sure to report to a supervisor and the patient’s provider.
• Always document patient care at the time provided to avoid forgetting details later on. If something must be added later to documentation, always indicate that information with a notation that it is a late entry, and include the time and date.

Don’t’s

• Don’t document a symptom (e.g., “c/o pain”) without also documenting how it was treated.
• Never alter a patient’s record (a criminal offense).
• Don’t use shorthand or abbreviations that are not approved.
• Don’t write imprecise descriptions, such as “a large amount.”
• Don’t document excuses, such as, “Medication not administered because it was not available.”
• Never document what someone else said, heard, felt, or experienced unless the information is critical. If absolutely needed, use quotations and properly attribute the remarks.
• Never document care ahead of time, as situations often change; documenting care that has not been performed is considered fraud.
  (NSO, 2021)

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, 2021a).

(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, 2021c)
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.