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Objective: To examine the content, quantity, and quality of multidisciplinary team documentation of 'communication' in hospital progress notes of patients with communication disability, and to explore the relationship of this documentation to patient safety. Design: Retrospective chart review involving a descriptive analysis and a qualitative content analysis of the progress notes. Setting: Acute medical and rehabilitation wards in two regional hospitals in one health district in Australia. Participants: Eight patients with communication disability who had experienced documented patient safety incidents in hospital. Methods: In total, 906 progress note entries about communication during 38 hospital admissions were extracted from eight patient's charts; written by staff in 11 different health disciplines. Data were analysed descriptively according to quantity, and qualitatively according to the content. Results: Four content categories of meaning in progress note entries relating to communication were (1) use of communication diagnostic and impairment terms; (2) notes on the patient's communicative function; (3) reports of the topic or content of the patient's communication attempts; and (4) references to third parties communicating for the patient. Communication-related information was often brief, unclear, and/or inaccurate. Descriptions of communicative function and recommended strategies for successful communication were often lacking. Conclusion: The suboptimal documentation of patient communication in progress notes may contribute to the higher risk of patient safety incidents for hospital patients with communication disability. Increased accuracy in documenting communication disability and function in progress notes might assist staff in communicating with these patients and improve the quality and safety of their care. [ABSTRACT FROM AUTHOR]

The purpose of this qualitative study was to identify differences in the utilisation of an electronic medical record test–result management system between two acute care departments. Field observations (130 min) and semi-structured interviews (n = 24) were conducted in the Intensive Care Unit and Emergency Department of an Australian hospital. Work processes identified from audio transcripts were modelled using business process modelling. Comparison of the Emergency Department and Intensive Care Unit identified the following: (1) test ordering variations according to clinical roles, (2) differences in the use of electronic medical record functionality according to specific demands of the clinical environment and (3) the non-linear components of the test–result management process. Variations were identified in the number of process decisions, external collaborations and temporal process workflows. Modelling the business processes, collaboration and communication needs of individual clinical environments can aid in enhancing the quality and appositeness of health information technology interventions and thus contribute to improving patient safety. Future health information technology interventions/evaluations aimed at improving the safety of test–result management processes need to address both the nuances of the clinical environment and accommodate the individual work practices of clinicians within that environment. [ABSTRACT FROM AUTHOR]

We sought (a) an inductive understanding of patient and clinician perspectives and experiences of the communication of diagnostic test information and (b) a normative understanding of the management of uncertainty that occurs during the clinical encounter in emergency care. Between 2016 and 2018, 58 interviews were conducted with patients and nursing, medical, and managerial staff. Interview data were sequentially analyzed through an inductive thematic analysis, then a normative theory of uncertainty management. Themes of "Ideals," "Service Efficiency," and "Managing Uncertainty" were inductively identified as influencing the communication of diagnostic test information. A normative theory of uncertainty management highlighted (a) how these themes reflected the interaction's sociocultural context, encapsulated various criteria by which clinicians and patients evaluated the appropriateness and effectiveness of their communication, and represented competing goals during the clinical encounter, and (b) how systemic tensions between themes accounted for when diagnostic test information communication occurred, was deferred or avoided. [ABSTRACT FROM AUTHOR]