The importance of communication and good recording in the medical record was reinforced several times as the "health disasters you hear about are all about failures of communication and failures of documentation" (GP4).
With our checklist, we aimed to support the communication and documentation of indications for the initiation and continuation of antibiotic therapy, which served to remind the treating physician to review and potentially stop therapy or target the isolated pathogen.
Studies looking at handover communication between nursing staff, found that a combined oral and written communication at handover achieved higher standards of documentation of care, than if verbal communication alone was used.
Gardiner P, Filippelli AC, Kabbara K, Lin SC, Sadikova E, Kaptchuk TJ, Kemper K. Online Education for Improving Communication and Documentation of Dietary Supplements Among Health Professionals Practicing in a Hospital Setting.
Poor documentation of indications for medications and follow-up advice is worrisome as it could either be due to lack of communication or documentation or both.
Other clinical issues included the quality of communication and documentation, preoperative and postoperative care, adverse events and protocol issues.
All these classification tools are useful in the context of communication and documentation among nurses, and well implemented in clinical practice.
The review of documentation on communication systems at district level as well as observations of communication patterns showed that information for PS was progressively communicated through memos, notices, megaphones and sometimes through door to door campaigns with the use of the neighborhood health committees.
Both these changes in the shortening of communication activities may be related to an increased reliance upon electronic communication and the greater use of clinical information systems reducing both the level of verbal communication required and the amount of documentation.
The significant variability in results and the consequence on structural safety of this investigation emphasizes the importance of documentation and communication of all the assumptions made by the structural engineer – even the apparently obvious ones.
Several possible factors could have contributed to our findings of a low rate of documentation of communication abilities.
