Abstract
BackgroundLittle is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.MethodsThis was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.ResultsA total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9–2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31–53%]. Qualitative analyses identified eight themes related to focus (central point – e.g., problem list), structure (organization, – e.g., note-taking style), and purpose (intention – e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority.ConclusionsImportant gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.
Highlights
Little is known about documentation during transitions of patient care between clinical specialties
Physician progress notes within each record were collected for up to ten consecutive calendar days depending on the length of hospital stay: up to 2 days in intensive care unit (ICU) before transfer, the day of transfer, and up to 7 days after transfer to the accepting hospital ward
One ICU (Hospital H) used an electronic Word document template to type progress notes that were subsequently printed on a separate piece of paper for placement in the medical record
Summary
Little is known about documentation during transitions of patient care between clinical specialties. We examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks. The medical record is central to this process because it is the repository for documenting events [22, 23], current issues [24], and services provided [25] It is a source of durable information that healthcare providers and in some institutions, patients [26, 27] can access when making clinical decisions [24, 28]. Our goal was to contribute to this gap in the literature by describing current textbased communication practices during transfers of patient care from ICU to a hospital ward, and identifying opportunities to improve communication and patient safety
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