Pocket Guide to Physician Communication

Documenting

Guide for Documentation in the Medical Record


D

Decision making - Explain diagnostic and therapeutic plan

O

Organization

C

Communicate clearly
Chronology of events
Compensation

U

Unapproved abbreviations - Do not use

M

Medical legal document - thorough, accurate, and factual

E

Error correction - Strike out. Do not alter.

N

Need date and time

T

Timely - Any change in patient status or management plan

I

If you don't document it, it didn't happen
Identification - Make sure you document in the right chart

N

Name - Print and/or stamp under your signature
Neat - Must be legible

G

Go over your dictation before signing


Aditi Singh, MD and Sandhya Wahi-Gururaj, MD, MPH

Signout?

Guide for Oral Sign-Out Skills


S

Sick or DNR? - highlight sick or unstable patients
identify DNR/DNI patients

I

Identifying data - name, age, gender, diagnosis

G

General hospital course

N

New events of day

O

Overall health status/clinical condition

U

Upcoming possibilities with plan, rationale

T

Tasks to complete overnight with plan, rationale

?

Any questions?


Horwitz, L, Moin, T, and Green, M. Development and Implementation of an Oral Sign-Out Skills Curriculum. JGIM 2007 October; 22(10): 1470-1474.

Soaps

Guide to Teaching Oral Case Presentations


S

Story - Identifies and describes complaints

O

Organization - Facts are where the listener expects

A

Argument - "Makes the case" for the assessment and plan

P

Pertinence - Only includes information relevant to the assessment and plan

S

Speech - Fluent, well spoken and not read


DeCherrie, L, Fagan, M, Green, E, Greenwald, J, Hershman, W, Sharpe, B, Torres-Finnerty, N, Wahi-Gururaj, S and Wiese, J. Making SOAPS safer. POGOe - Portal of Geriatric Online Education; 2006 Available from: http://www.pogoe.org/productid/18900

Safety

Resident Guide for Attending Input


S

Seeking attending input early often prevents delays in care

A

Active clinical decisions (e.g. surgery) should be made after contacting your attending

F

Feeling uncertain about clinical decisions is normal - you should contact your attending

E

End of life care decisions change the course of care, and the attending should be aware of the discussion

T

Transitions of care - Contact your attending if someone is being discharged or transferred

Y

sYstem difficulties and hierarchy may hinder patient care - attendings can help expedite care through direct involvement


Farnan JM, Johnson JK, Meltzer DO, Harris I, Humphrey HJ, Schwartz A, Arora VM. Strategies for effective on-call supervision for internal medicine residents: The SUPERB/SAFETY model. Journal of Graduate Medical Education. 2010;2(1):46-52.

Superb

Guide for Attending Supervision


S

Set expectations for notification – Be notified when a patient is being discharged, transferred, going to surgery, dies, or leaves AMA

U

Uncertainty – Ask the resident to contact you when feeling uncertain about specific decisions

P

Planned communication – Set a time to talk to your resident on call nights and before leaving the hospital each day

E

Easy availability – Provide resident with your contact information

R

Reassure fears – Reassure the resident that calling is not a sign of weakness and that you would not be upset by the call

B

Balance supervision and autonomy – Tailor for level of resident experience


Farnan JM, Johnson JK, Meltzer DO, Harris I, Humphrey HJ, Schwartz A, Arora VM. Strategies for effective on-call supervision for internal medicine residents: The SUPERB/SAFETY model. Journal of Graduate Medical Education. 2010;2(1):46-52.