Patient Safety and Clinical Communications

the following lecture is brought to you by the boot camp subcommittee of the Committee on Resident education of the Society of Neurological Surgeons neurological surgery residents have a tremendous responsibility you represent your service and attendings you are elite and held at the highest standards you are called on to manage the terror you must remember the burden of their patients and families you must carry yourself with the utmost respect for patient family coworkers and staff patient communication has a purpose and importance to share information with other health care providers and provide continuity to provide history of a patient's illness medical legal documentation anything you write can and will be used in a court of law and public opinion billing and coding part of teamwork primary patient safety issue the single most important aspect of communication is to stop focus and listen there is no multitasking in communication when communicating and documenting be sure to consider the following in neurological surgery we may never have the opportunity to speak with our patient communication with the family is also our responsibility understand whom is the legal voice of the family elicit the level of the patient or family's understanding of the situation ask if you are understood and if there are any questions be patient do not be afraid to say I do not know remember to summarize and reinforce your discussion families and patients under stress may be distracted patients whom are having difficulties may need more communication not less there are several key elements to documentation and communication timing and timeliness critical events and values accurate detailed and concise do not use abbreviations for example Perla never alter a medical record unless stating that you are correcting an error read before you countersign minimize copy and paste no derogatory statements chart wars subjective remarks or non patient care information if it is not written you did not do it how and with whom we communicate determines our success it can be verbal nonverbal written with nurses and allied health care providers patients family colleagues remember respect is key always there are numerous types of documents you will be dealing with history and physicals admit notes consultations consents operative and procedural notes phone interactions progress notes discharge summaries handoff documents and communication as well as hospital and physician billing documents admission notes should have the following components history of present illness review of systems medications allergies family history social history a detailed examination review of studies assessment and plan consult notes should restate the patient's clinical condition summarize in detail the neurological examination summarized in detail the radiological studies and clearly state the assessment and treatment plan leave a page number for additional questions contact the service asking for the consult and talk with them specifically making sure you have answered the question be timely be prompt and be courteous if people ask you to see a patient it is because they are asking for your help operative of procedural notes should include pre and post-operative diagnosis indications and consent procedural side sight and levels surgeon and assistance anesthetic type blood loss and fluid replacements findings surgeons presence specimens post-operative condition and disposition always remember your audience yourself billing and coding future surgeons caregivers and legal review consent is a process it is a conversation document it in your note must be condition procedure alternatives risks benefits questions and agreement when getting consent remember to consider the following factors consent is given voluntarily and can be withdrawn at any time it is a timed document should be procedurally and patient specific is necessary for all therapeutic and diagnostic procedures must be obtained by knowledgeable physicians the signed form is an important documentation of the informed discussion conversation special issues that may arise involve minors difficult patients emergencies cognitive disabilities power of attorney and language cultural religious barriers you must understand whom is an appropriate and legal interpreter treatment without consent can be construed legally as battery failure to obtain proper consent can be construed as malpractice the discharge summary is extremely important for continuity of care remember to include key elements of the hospital course such as chief complaint diagnostic findings therapies and procedures response to treatment disposition at discharge appropriate dates of events medications on discharge and discharge instructions handoffs are a necessary part of shift work it is important to remember however that sign outs are a major source of medical errors and malpractice claims as well as a reflection of the team's ability to communicate and offs can place a patient at risk as the most sensitive tests to follow a patient's course is serial neurological examinations by the same observer the structured handoff can be summarized by the mnemonic seem summary situation and/or status every active major clinical status and management and planned next steps related to each major clinical issue it is important for the clinician receiving the information to be able to ask questions call early and call often do not be afraid to call your chief or attending for information and advice especially over the weekend the attending may be the person who has the most continuity of care the nurses spent 8 to 12 hour shifts at a time with the patient they make serial observations when they call go see the patient billing and coding might not seem important right now but will be vital in your future they are generated off your documentation with medical and legal consequences they are determined by codes CPT icd-9 inpatient outpatient procedural modifiers new and established components include history examination medical decision making other contributing components include the extent of counseling and coordination of care with others nature of the presenting problems complexity and time conflicts will occur and they are usually due to Allah of communication they are inevitable so expect them in conflict you have a choice patient safety is our primary goal try to see what is the benefit to the other person are you going to work with this person again does your boss really want to hear what you said keep the patient not your ego at the center of the discussion some conflict is good and necessary for the long-term benefit of the patient most importantly conflict can hinder communication leading to a patient safety issue in summary communication and documentation are part of your professional responsibilities accurate timely and pertinent documentation is crucial for good patient care and a potent force against malpractice communication and documentation play a critical role in durable handoffs which are crucial to good patient care and also a potent force against malpractice communication and documentation are part of the ongoing process of patient care and education between the physician patient family and healthcare partners

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