Recording essential information
Inadequate medical records are the underlying cause of many failures of communication – the records are the essential tool of communication between members of the multidisciplinary team. Subtle but significant changes may be missed when several different doctors see a patient over many days, unless adequate information is available from previous examinations.
Subtle but significant changes may be missed when several different doctors see a patient over many days
What you include or leave out of the record is a matter of professional judgment, but you should take care to include all information that other members of the team will need to continue care of the patient safely. As months or years may elapse between treatments or illnesses and staff may have changed in the meantime, the records should also serve to reconstruct events at a later date without recourse to memory. Advice on what to include in the medical record can be found here.
For hints on keeping good records, and advice on access to and disclosure of medical records, phone or email MPS’s communications department and request a copy of the MPS booklet, Medical Records – An MPS Guide.
Handover
Responsibility for the average patient’s care passes between numerous healthcare teams during the course of one episode of hospitalisation. And to shift changes and transfers between departments and specialty units must be added the transfer of the patient from primary to secondary care and back again. Each transition from one setting to another, or from one team to another, represents a heightened risk for the patient. One of the most common root causes of medical mishaps is communication failure during the transfer of care.
Given the potential for communication breakdown at each transfer, it’s little wonder that poor handover has been identified as a root cause of so many medical mishaps (see Box 16). The World Health Organisation recommends that handovers between shifts and between units should:13
- “Use a standardized approach to minimize confusion.
- Allocate sufficient time for staff to ask and respond to questions.
- Incorporate repeat-back and read-back steps as part of the hand-over process.
- Limit the exchange to information that is necessary to providing safe care to the patient.”
Each transition from one setting to another, or from one team to another, represents a heightened risk for the patient
Box 16: An international concern
“Breakdown in communication was the leading root cause of sentinel events reported to the Joint Commission in the United States of America between 1995 and 2006 and one USA malpractice insurance agency’s single most common root cause factor leading to claims resulting from patient transfer.
Of the 25,000 to 30,000 preventable adverse events that led to permanent disability in Australia, 11% were due to communication issues, in contrast to 6% due to inadequate skill levels of practitioners.”
Source: WHO Collaborating Centre for Patient Safety Solutions, Communication During Patient Hand-Overs, Patient Safety Solutions, vol. 1: solution 3 (May 2007)
SBAR is in many respects an ideal communication model in healthcare because it’s not only simple and easy to remember, but is also flexible
One communication technique that seems to be finding wide favour globally is SBAR (Situation – Background – Assessment – Recommendation). SBAR is in many respects an ideal communication model in healthcare because it’s not only simple and easy to remember, but is also flexible, and therefore as applicable for a nurse phoning the on-call doctor with concerns about a patient in the middle of the night as it is for a formal handover between shifts.
Organisations that have adopted SBAR report that it’s played a vital role in overcoming the traditional communication barriers between professionals of different status. This is absolutely crucial.
There have been too many instances where nurses and junior doctors have known perfectly well that something is amiss, but haven’t felt able to voice their concerns in unambiguous terms to senior clinicians. Classically, in these situations, they adopt a “hinting and hoping” mode of communication – ie, hinting at what they think needs attention and hoping that the hint will be taken.
To be truly effective, SBAR should be adopted by a whole team (and preferably throughout the hospital) and everyone should be given training in its use. However, there’s nothing to stop individuals using it independently as an efficient means of structuring information.
Its advocates have also found it useful for structuring reports, letters and medical notes. The description in Box 17 sets out the essential structure of the model, but further information can easily be found on the internet.
To be truly effective, SBAR should be adopted by a whole team (and preferably throughout the hospital)
Box 17: SBAR
S – Situation: What is happening at the present time – ie, who you are, who the patient is, the patient’s location and current condition. Briefly state the problem and/or your concern clearly at this point.
B – Background: The circumstances leading up to this situation, ie, a brief summary of relevant past medical history, the admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results. Include most recent vital signs, important observations outside normal parameters and your clinical impression.
A – Assessment: What you think the problem/diagnosis/appropriate management is – eg, patient is deteriorating/stable, requires monitoring, is at risk of haemorrhage/shock.
R – Recommendation: What should be done to correct the problem/manage the patient/monitor the situation/maintain continuity of care – eg, awaiting lab results which must be acted upon as soon as they’re available, keep an eye on fluid balance, set up IV if necessary, watch for signs of internal haemorrhage.
The SBAR tool originated in the US Navy SEALS and was adapted and developed for a healthcare setting by Kaiser Permanente.
Keeping contact details up-to-date
If you carry a bleep, you have a responsibility to make sure that everyone who needs it knows its number. When you come on duty, you should write it on the handover sheet during handover, and if you’re on call, you should ensure that the ward staff know how to contact you.
You also have a responsibility to keep switchboard informed of your contact details. It is especially important to keep switchboard informed about your whereabouts if you’ll be travelling between sites – to an outlying clinic, for example.
It goes without saying that you should inform the hospital whenever your contact details – mobile or landline number, address and email address – change. It’s surprising how often people forget to do this, but such a seemingly small oversight can lead to big consequences if you can’t be contacted in an emergency. You might, for example, have forgotten to pass on some important information about a patient before you went home, and if you can’t be contacted no-one can ask you about it, which may prove crucial in an emergency.
If you’re on call, you should ensure that the ward staff know how to contact you
Referrals
Referrals are another form of transfer of care, so you should ensure that all the essential information about the patient is conveyed to the receiving consultant. A tool like SBAR can be used for structuring the referral letter. Include an indication of the level of urgency of the referral.
Remember to tell the patient (or the patient’s carer) why you are making the referral and let them know what they can expect.