BACKGROUND: Standardization of sign-out, the transfer of patient information and responsibility between inpatient providers at shift change, is a Joint Commission National Patient Safety Goal intended to improve communication and reduce risk of error. Computerized systems with free text data entry and limited structure allow clinicians to generate sign-out notes in a variety of ways. OBJECTIVES: The literature lacks a systematic exploration of the range of content generated by users of computerized sign-out systems. The goal of this study was to determine if and how clinicians record standardized sign-out information using a system with free text data entry and limited structure. METHODS: Using qualitative methods, we reviewed free text sign-out notes for 730 patient cases across 39 hospital units at an academic medical center. RESULTS: Two categories of information expression emerged from analysis: patient treatment-comprised of patient summaries, awareness items, and action items-and care team coordination-consisting of discharge information, contact information, and social concerns. A third category describing the format of sign-out note content, presentation of information, also emerged. Location and structure of information varied, but sign-out note content for some hospital units exhibited specific characteristics and was relatively standardized. CONCLUSIONS: Findings provide a baseline understanding of computerized free text sign-out note content. Sign-out notes contained a synthesis of data from disparate sources. We recommend formalizing existing unit-specific content standardization and system use patterns to reduce sign-out note variability and improve communication.
BACKGROUND: Standardization of sign-out, the transfer of patient information and responsibility between inpatient providers at shift change, is a Joint Commission National Patient Safety Goal intended to improve communication and reduce risk of error. Computerized systems with free text data entry and limited structure allow clinicians to generate sign-out notes in a variety of ways. OBJECTIVES: The literature lacks a systematic exploration of the range of content generated by users of computerized sign-out systems. The goal of this study was to determine if and how clinicians record standardized sign-out information using a system with free text data entry and limited structure. METHODS: Using qualitative methods, we reviewed free text sign-out notes for 730 patient cases across 39 hospital units at an academic medical center. RESULTS: Two categories of information expression emerged from analysis: patient treatment-comprised of patient summaries, awareness items, and action items-and care team coordination-consisting of discharge information, contact information, and social concerns. A third category describing the format of sign-out note content, presentation of information, also emerged. Location and structure of information varied, but sign-out note content for some hospital units exhibited specific characteristics and was relatively standardized. CONCLUSIONS: Findings provide a baseline understanding of computerized free text sign-out note content. Sign-out notes contained a synthesis of data from disparate sources. We recommend formalizing existing unit-specific content standardization and system use patterns to reduce sign-out note variability and improve communication.
Authors: Jeffrey L Schnipper; Jeffrey A Linder; Matvey B Palchuk; Jonathan S Einbinder; Qi Li; Anatoly Postilnik; Blackford Middleton Journal: J Am Med Inform Assoc Date: 2008-04-24 Impact factor: 4.497
Authors: Joshua Davis; Lee Ann Riesenberg; Matthew Mardis; John Donnelly; Branden Benningfield; Mallory Youngstrom; Imelda Vetter Journal: J Grad Med Educ Date: 2015-06