Delay in patient care if information not provided in a timely manner Referring physician frustration as referring question not answered; this may generate another referral posed in the referral letter STYLE Disorganized content and lack of content planning Wordy No attention to visual layout with no white space Lack of content planning, organization, and white space, making the letter difficult to scan by a busy clinician letter filled with medical jargon and filler words that do not add to the meaning of the letter Encourage the learner to use templates for conditions commonly seen Tell the learner to review all dictations before sending so they can pay attention to the visuals of the letter (white space) and check for errors Encourage the learner to use bullet points in the body of dictation (e.g. history of presenting illness, physical examination) Encourage the learner to use numbered lists (e.g. past medical history, medications, plan) Encourage the learner to use tables to reflect a lot of information in a visually effective manner (e.g. table for muscle grading numbers) DIAGNOSTIC IMAGING CONSULTATION REPORT Description of findings is poor, vague, variable, or inconclusive, with a lack of detail Frustration on referring physician’s part Potential for misunderstanding regarding diagnosis and next steps, leading to inappropriate use of resources (i.e. unnecessary additional tests) Patient safety may be compromised if there is a delay in treatment because it was not clear additional tests were needed Variable approaches in diagnostic imaging are a common problem. Ensure the learner chooses one approach that they are able to articulate and routinely use Create a template of acceptable phrases for common findings and opinions the learner to synthesize and consolidate clear findings, opinions, and management plans
LABORATORY REPORT, CONSULTATION REPORT Poor or vague impressions of the case with an unclear statement of reasons for the uncertainty Report reader may make incorrect assumptions, potentially impacting treatment recommendations Delays in treatment Requests for second opinion via clinician Provide templates for common diagnoses Teach the learner to outline the key concepts to be transmitted before writing the draft report Incomplete report (missing parameters) Delayed treatment Requests for review of case (duplication of work) Rather than rely on electronic synoptic reporting systems, the learner may write a draft report, including all necessary parameters Encourage reference to College of American Pathologists’ cancer reporting protocols for draft writing Incorrect use of language Use of non-conventional terminology Improper grammar and ambiguities may lead to reader misunderstanding of the severity of findings Delays in treatment Requests for review of case (duplication of work) Provide a list of standardized (conventional) terminology Teach the learner to outline the key concepts to be transmitted before writing a draft SURGICAL – OPERATIVE REPORT Abbreviations used without citing specifics (e.g. AVSS) Missing pertinent information (e.g. intraoperative findings, blood loss, placement of drains, pathology pending, intraoperative complications experienced, etc.) Incorrect or incomplete procedure recorded Using abbreviations that are not known can result in misunderstanding of patients needs and / or delaying further intervention or alterations in management due to confusion Missing information that can direct and alter care, investigations, or monitoring Incorrect drains, etc., may be removed (especially in cases of multiple drains) Perception of patient having undergone incorrect procedure leads to miscommunication with the patient, family, and consultants, and Teach the learner to look up and record the appropriate specific pertinent vitals (HR, BP, SaO2, Temp, urine output) Teach the learner to ask for and record the various important surgical aspects the learner to clearly label and record positions of drains (use diagram if necessary) the learner to discuss procedure performed with MRP so that it can be adequately reported in the chart
creates potential for confusion and loss of faith in the system and team SURGICAL CONSULTATION REPORT A diagnosis but no recommendations Further investigations Improper follow-up Inaccurate expectations around recovery process Missed opportunity to educate the physician Teach the learner how to incorporate continuing professional development into consultation letters (e.g. include relevant references, summary of clinical practice guidelines; incorporate education paragraphs about specific treatment, etc.) DISCHARGE SUMMARIES Lack of a discharge plan, with far too much focus on the details of what transpired and little information on the next steps and who is responsible for following up on the issues identified Delay in discharge note Patient safety is compromised Confusion and frustration for the primary care physician and community services providing Delay in needed services Tell the learner that it is critical to summarize major medical and surgical issues that transpired during the course of admission — it is easier to review the details if they are organized in a format that can be readily scanned (numbered list of issues, with descriptions) Explain that the discharge plan must be detailed enough to include the next steps post-discharge, who will do what, and what the patient has been told if the discharge plan isn’t successful. Specifically, the discharge summary needs to clearly identify the expectations of the primary care provider Provide clear guidelines for the completion and delivery of discharge notes