Taking great care with patient care information

Thursday, July 31, 2014 - 4:02pm

Documenting and communicating patient care information among health care providers, patients and families is critical to the best possible patient care. Not documenting and communicating patient information appropriately can put patient safety at risk.

This is why efforts are underway at Capital Health and in hospitals, health centres and health professional schools across Canada to ensure documentation and communication are complete, accurate and consistent.

“Time constraints, disruptions, communication styles, and lack of standards, processes and tools all impede documentation and communication,” notes Dr. Stavros Savvopoulos, district medical director for hospital care at Capital Health. “Studies in this area show that ‘transition points,’ when accountability for a patient’s care is transferred from one health care provider to another, are when documentation and communication most often fail.”

The amount of information exchanged among health care providers, a patient and his or her family to support just one patient’s care is staggering. This includes everything from seemingly simple data, like a person’s age and weight, to complex test results and next steps in a patient’s care. There are also dates, times, symptoms, medications, allergies, and the list goes on. Similar to puzzle pieces, each piece of information builds on the other to inform one’s care. And similar to fitting a puzzle’s pieces together, appropriately documenting and communicating patient information is critical.

“Safe transitions in care are paramount to patient safety,” says Hugh MacLeod, CEO, Canadian Patient Safety Institute. “This is why ASK. LISTEN. TALK. is the Canadian Patient Safety Institute’s key message to both health care providers and patients. Our work tells us that communication and documentation can and do have a major impact on the safety of the care we provide.”

Health organizations are now tackling the issues with education, standardized practices and tools to capture necessary information – all of which are being employed at Capital Health.

“We are currently focused on two specific areas: ensuring essential documentation and communication among health care providers when a patient is in hospital; and ensuring appropriate documentation and communication among health care providers, patients and families when a patient is discharged from hospital,” explains Dr. Steven Soroka, vice president of medicine at Capital Health. “Results from a recent survey are promising and show that we are headed in the right direction.”

One of those directions is development of an electronic tool that helps physicians and other health professionals document appropriate information when a patient is discharged.

“eDischarge prompts physicians to document appropriate information and then provides copies of pertinent information to patients and their family physician,” says Dr. Savvopoulos. “Completing diagnosis, treatment, instructions for followup and other required information is mandatory. The tool was developed at Capital Health and is now available to all areas of the district.”

Dr. Hani Mufti, a fifth-year cardiac surgery resident, has been using eDischarge for a few months. He says that while the system is a work in progress, it has made his job easier and lessened the potential for information gaps.

“It’s in real time so I prepare the discharge summary as I see the patient,” he says. “When the discharge summary is signed-off by the accredited physician, it automatically goes to the patient’s family physician – done.”