Baystate Medical Center has taken many steps to assure that communication among healthcare providers is clear and effective. The SBAR tool (situation, background, assessment, request and/or recommendation) is promoted as a universal communication tool, is the most commonly used mechanism for communication of critical information from the ED to patient care units, change-of-shift/coverage, and was our first step in standardizing communication. Other tools that are used to share information vary depending on the specific needs and interests of the department, but usually include one or more assertive communication tools. One of the tools was designed as a result of a multidisciplinary collaboration – the CIS Hand-Over Tab. The tab uses the SBAR structure in our electronic medical record (CIS). Testing and adoption on pilot units led to elimination of paper-based tools for recording patient information – the units rely solely on the CIS Hand-Over Tab for communication between shifts and between caregivers. We also utilize a “Ticket to Ride” tool to share important patient information with staff in procedural or testing areas. The “Ticket to Ride” is populated via the CIS documentation which eliminates errors due to duplicate documentation. Modifications to the hand-over tab and the “Ticket to Ride” tool will be based on improved functionality of the CIS system. Staff feedback continues to drive modification, and the goal is to have the tab become the universal conduit for sharing patient information between caregivers across the health system.
- The Hand-Over Tab contains essential patient information that is used by clinical staff to support the plan of care.
- The Hand-Over Tab takes the place of previously used documents, and includes information on the patient’s past medical history, pending items, a “To Do” list, contingency plans, and anticipated discharge date.
- Nursing physical assessment information has been added.
- The Physician Hand-Over section is populated by a PowerNote that the physician completes daily. This allows for smooth transitions and consistent care delivery.
- Nursing has access to this information, and physicians can identify which nurses and hospital case managers are caring for their patients at any given time.
The approach of developing one tool for the care delivery team was recognized by Cerner as innovative, and the implementation team presented a learning session in the Patient Care Track of the National Cerner Health Conference.
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