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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.

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.


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 14).

The World Health Organization recommends that handovers between shifts and between units should:

  • “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.”13
Of the 25 000 to 30 000 preventable adverse events, 11% were due to communication issues

Box 14: 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.”

(WHO Collaborating Centre for Patient Safety Solutions, Communication During Patient Hand-Overs, Patient Safety Solutions, vol. 1: solution 3 (May 2007))

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 15 sets out the essential structure of the model, but further information can easily be found on the internet.

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

Box 15: 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.)


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.

Case report: Poor communication with blinding results

A month later, he was seen in the diabetic clinic but there was no discussion of his TB treatment

A diabetic clinic in a teaching hospital diagnosed TB in a diabetic patient with a history of weight loss. He was admitted to hospital and, on discharge, was prescribed three months’ supply of ethambutol, rifampicin, pyrazinamide, isoniazid and pyridoxine.

A month later, he was seen in the diabetic clinic but there was no discussion of his TB treatment. He failed to attend his next appointment.

Three months after starting TB treatment, the patient began to complain of deteriorating vision and his GP made an urgent referral to the eye clinic. The GP had not yet received a discharge letter about the patient’s last hospital admission for the treatment of TB, nor had the diabetic clinic informed him of the diagnosis, so his referral letter to the eye clinic made no mention of the fact that the patient was taking ethambutol.

The patient attended the eye clinic several times over a month, but no history of TB or treatment for TB was obtained – his visual loss being attributed to diabetes. However, his vision continued to deteriorate and by the end of this period he was only capable of counting fingers. A week later, the patient attended the diabetic clinic. Only then was the diagnosis of ethambutol eye toxicity raised. The patient was seen immediately in the eye clinic where the diagnosis was confirmed and the ethambutol stopped, but by then he had sustained a permanent loss of 90% of his vision.

Communication with colleagues in primary care

The divide between primary and secondary care is an area where communication can easily break down, particularly when patients are receiving long-term treatment. If the patient is being given ongoing care as an outpatient it is particularly important to keep the GP informed about his or her progress and treatment, as they may have a bearing on the GP’s own treatment of the patient (see a related case report).

Delays in mailing discharge summaries to GPs are another common cause of adverse incidents. Patients’ GPs should be notified whenever their patients are seen in secondary care, and especially if they’ve referred the patient themselves. As the GP is often familiar both with the patient’s past medical history and with relevant family history, their concerns and suggestions should be taken seriously.

Patients’ GPs should be notified whenever their patients are seen in secondary care, and especially if they’ve referred the patient themselves