Communication and Documentation

Communication

Clear communication is imperative in the health care environment and occurs between various individuals on a daily basis by way of verbal, non-verbal and written communication. Communication is essentially the activity of relaying information, expressing emotions and building relationships (Smallwood, 2011). in order for trust to develop between healthcare providers and their patients/residents, it is important that effective communication is developed and maintained.

Effective communication between healthcare providers is extremely important to patient/resident safety. Students lack experience in communicating with physicians and other healthcare providers. The SBAR (situation, background, assessment, recommendations) communication technique provides an organized logical sequence and improved communication process to ensure patient/resident safety.

The Joint Commission (2012), has added "standardized communication" to the Patient Safety Goals. SBAR is a communication technique and stands for:

  • SITUATION: What is the situation? Why are you calling the physician? What is happening at the present time? What is the acute change? Explain in the fewest words, exactly what the situation is.

  • BACKGROUND: What is the background information? What are the vital signs and pertinent history? Explain how the situation came to be? What were the circumstances leading up to this situation?

  • ASSESSMENT: What is your assessment of the problem? What do you think the problem is?

  • RECOMMENDATION: What should we do to correct the problem/address the situation? What action/response do you propose?


    Example: Call to Physician
Situation
Dr. Patel this is Mary from Unit 8. I'm calling about your patient, Mr. Robert Smith in room 810 and wanted to let you know his heart rate has increased to the 150's and it is irregular. He does admit to feeling a little dizzy, short of breath and complains of palpitations.
Background
Your patient walked for the first time since returning from a percutaneous endoscopic gastrostomy (PEG) placement this morning. His PEG site looks fine. Prior to the walk, his pulse was in the 90's at rest with blood pressure of 110/70. After applying O2 at 2 liters nasal cannula, his O2 sat increased to 96% from 94%."
Assessment
I think this change in heart rate with exertion is causing him to be symptomatic. After the walk his pulse return to 96 with rest.
Recommendation
I would like you to see Mr. Smith as soon as you can. In the meantime, I will have Mr. Smith continue to rest in bed or sitting in the chair with his O2 on. Would you like a 12-lead EKG done at this time?


SBAR can be applied to almost all forms of communication between healthcare providers and thus provides a standard framework to transfer important information. SBAR helps students organize their thoughts prior to calling physicians, during handoff to another healthcare provider, and when transferring patients to other organizations or levels of care.

SBAR communication technique for shift change report:

  • SITUATION: Patient's/Resident's name, room number, age, diagnosis, chief complaint, medications and allergies.

  • BACKGROUND: Medical history.

  • ASSESSMENT: Observations, such as VS, pain assessment, bowel sounds, lung sounds, current IV lines.

  • RECOMMENDATION: Patient's/Resident's care plan.

Documentation

Documentation is a vital component of safe, ethical, and effective patient/resident care practice, regardless of whether the documentation is paper-based or electronic. Documentation provides a mechanism to describe, record, and communicate data, information, knowledge, and wisdom about a patient/resident; the care provided; the effect of care and the continuity of care. Documentation also provides a legal record of care provided. “Specific principles, standards, policies, procedures, and processes are part of any documentation system and help present the content in meaningful ways (ANA, 2007)”. Students need to be familiar with and follow the health care organization’s policies, standards and protocols.

Documentation for an individual patient/resident, whether paper-based or electronic, should clearly describe:

  • An assessment of the patient’s/resident’s health status.
  • A care plan or health plan reflecting the needs and goals of the patient’s/resident’s care needs.
  • The interventions carried out.
  • Patient/resident and family teaching.
  • The patient’s/resident’s response to the intervention.
  • Information reported to a physician or other healthcare provider and, when applicable, that provider’s response.
  • Advocacy taken by the healthcare provider on behalf of the patient/resident.
  • Any proposed or needed changes.

DOCUMENTATION STANDARDS

Regardless of the system used to document, the student maintains documentation that is:

  • clear, concise and comprehensive;
  • accurate, true and honest;
  • relevant;
  • reflective of observations, not of unfounded conclusions;
  • timely and completed only during or after giving care;
  • chronological;
  • a complete record of care provided, including assessments, identification of health issues, a plan of care, implementation and evaluation;
  • legible and non-erasable;
  • permanent;
  • retrievable;
  • confidential;
  • patient/resident-focused; and completed using forms, methods, systems provided.

GUIDELINES

  • Document on the designated health care organization forms.
  • Ensure each form clearly identifies the patient/resident.
  • Document in permanent black ink.
  • Do not leave blank lines between entries.
  • Use only approved abbreviations and symbols.
  • Do not erase or black out an error and do not squeeze entries between lines.
  • Each entry must include the date, time, full legal signature and designation as a student and health professions program of the writer. The full legal signature consists of the first name and last name recorded. The instructor or preceptor must co-sign.
  • Never delete, alter or modify anyone else’s documentation.
  • Document only work done personally; never document for someone else.

  • Incorrect Written Entry
    • Erasures, whiteout, or alteration of spelling errors are not permitted — draw a line through the incorrect word such that it remains legible. The word “error” is to be marked and initialed.
    • For submission in wrong chart — place a diagonal line and write “wrong chart”. Date, time and sign.


  • Late Entry
    • Document forgotten or late entries at the next available entry space. Write the current date and time and write “Late entry for” date of missed entry.

DOCUMENTATION FORMS

Effective documentation forms provide a framework and guides documentation. Documentation forms include, but are not limited to:

  • Assessment.
  • Care plans.
  • Worksheets and Kardexes.
  • Flow sheets and checklists.
  • Monitoring strips.

ELECTRONIC HEALTH RECORD

If the health care organization uses an electronic health record, understand that the same documentation principles apply, although there will be different strategies to record data and to ensure privacy, security and confidentiality of the record, as stated in the HIPAA Orientation and Education.

REFERENCES

  • Dillon, P. M. (2007). Nursing Health Assessment: Student Applications, 2nd ed. Philadelphia: F.A. Davis Co.

  • Huiras, R. (2009). Kean Students Use SBAR Method to Improve Shift-Change Communication. Nurse.com. Retrieved from http://news.nurse.com/apps/pbcs.dll/article?AID=2009311160001.
  • Jarvis, C. (2007). Physical examination and health assessment. (5th ed.). Bloomington, Illinois: Saunders.

  • Massachusetts Department of Higher Education Nurse of the Future Competencies Committee. (2007). Nurse of the Future Nursing Core Competencies, version 2. Department of Higher Education: Boston, Massachusetts.

  • Potter, P. A. & Perry, A. G. (2009). Fundamentals of Nursing, 7th ed. St. Louis, Missouri: Mosby, Inc.

  • Smallwood, L. (2011, April). Effective Communication Tool for Student Nurses. Career Advice: Suite 101. Retrieved from http://linda-smallwood.suite101.com/student-nurses-effective-communication-tools-a363728.

  • Springerhouse. (2007). Lippincott Manual of Nursing Practice Series: Documentation. Wolters Kluwer/Lippincott/Williams & Wilkins Inc.

  • The Joint Commission. (2012, April). Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care A Roadmap for Hospitals. Retrieved from www.jointcommission.org/topics/patient_safety.aspx.

  • Thomas, C. M., Bertram, E., & Johnson, D. (2009). The SBAR Communication Technique: Teaching Nursing Students Professional Communication Skills. Nurse Educator, 34(4), 176-180.