Stein, Daniel M. MD, PhD; Stetson, Peter D. MD, MA
Dr. Stein is assistant professor of clinical biomedical informatics, Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, New York.
Dr. Stetson is chief medical informatics officer, ColumbiaDoctors, assistant professor of clinical medicine, Department of Medicine, and assistant professor of clinical biomedical informatics, Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, New York.
Correspondence should be addressed to Dr. Stein, Vanderbilt Clinic Building, Fifth Floor, 622 West 168th Street, New York, NY 10032; telephone: (212) 305-0601; e-mail: firstname.lastname@example.org.
The physician signout note is a widely used clinical document that supports patient safety and care continuity during patient handoff in the hospital. Despite its centrality to patient care, the signout note is not considered an official document, and it is, therefore, not generally standardized or taught to medical trainees, nor is it usually integrated into electronic health records (EHRs). This commentary outlines several of the potential advantages to establishing the physician signout note as an official part of the medical record, such as the facilitation of information flow between signout notes and other parts of the patient chart and the possibility of integrating decision support tools into this important aspect of the clinical workflow. The authors address frequently encountered concerns regarding the establishment of the signout note as an official part of the medical record. They conclude by making recommendations for integrating signout notes into EHRs and using modern, social Web technologies in such an implementation.
The physician signout note is a clinical document that supports physician communication and patient safety, especially during periods of “cross-coverage.” Yet, signout notes are overlooked during physician training, and standards for their use and rigorous evaluation of their implementation often are neglected, most likely because signout is not part of the “official” medical record. We believe this gap represents a missed opportunity to support physician workflow, clinical communication, and patient safety.
The Signout Note—A Key Tool for Patient Handoff Continuity
Care transitions in the hospital are necessary, commonplace, and oftentimes dangerous. A review of the literature on patient handoff between physicians highlighted the importance of effective communication on the quality and safety of patient care during this transition.1 We find it concerning, then, that handoff remains “vulnerable to communication failures” and is “remarkably haphazard.” Despite the strong evidence that patient handoffs have a significant impact on patient safety, scant studies of high quality have been done that provide evidence-based recommendations for making the end-of-shift handoff safer.
A key tool used by physicians to support patient handoff is the informal working document known as the signout note. Signout notes contain patient data that support informational continuity (history, medications, allergies, etc.) and management continuity (in the form of cooperatively managed “to-do” lists). As might be expected of an informal document, the written signout note is not taught and has not been standardized. A survey of internal medicine training sites across the United States showed that most programs did not provide training on handoff skills.2 Little uniformity exists across programs in terms of signout note content or implementation. Observations of resident handoffs have demonstrated a number of problems with the handoff system, including signout notes that lack comprehensiveness, variation in the quality of handoff communication, and information errors in sequential handoffs.3
Why Make the Signout Note Official?
That the signout note is not an official, standardized part of the medical record may explain why commercial electronic health record (EHR) systems provide no supporting tool for it. Yet, arguably, several advantages exist to integrating signout notes into current EHRs and to making them official, centrally distributable clinical documents, as we have done at NewYork-Presbyterian Hospital (NYP).
First, incorporating these data into the EHR facilitates the repurposing of rich, up-to-date clinical information typically cordoned off in the stand-alone signout note. For example, a patient's location in the hospital or primary care provider is sometimes accurately represented only in the signout note. This information may otherwise be inaccessible or out-of-date in the official patient record.4 Signout notes also contain a clinical narrative that is reliably available during and immediately after a patient's admission. A centrally accessible signout note is therefore useful in filling information gaps if, for example, a returning patient's discharge summary from a previous admission has not been entered into his or her chart yet. A local study of the EHR information-seeking patterns of emergency department staff, for example, showed that resident signout notes were one of the most frequently viewed sources of “old data” from a previous admission.5 Furthermore, when not kept solely in the pockets of physicians, health care staff in other disciplines often view signout notes. A local analysis of the use of our custom, EHR-integrated signout application at NYP revealed that physician assistants, nurses, pharmacists, social workers, and others frequently viewed physician signout notes. This practice was confirmed at another institution with centrally available signout notes and suggests that centralized and distributable signout notes would support improved interdisciplinary information exchange.6
A second benefit of supporting a centralized, official signout note system is enabling information to flow from other parts of the medical record into the signout note. For example, integration with an EHR allowed residents to spend more time at the bedside during prerounding by eliminating the error-prone and time-consuming process of manually recopying data into the signout note.7,8 Anecdotal reports from our residents support this finding, indicating that the ability to selectively import the data most often entered into signout notes (e.g., vital signs and recent lab results) saves time during prerounding.
Finally, there are tools applied to other areas of the EHR that would be useful when authoring and using signout notes. Alert systems that are generally used during order entry might be useful when authoring signout notes (e.g., “You have failed to put this patient on DVT prophylaxis”). Clinical decision support systems could also be beneficial. For example, when authoring a “to-do” list, integrated, interactive guidelines might result in better instructions for cross-covering providers that include robust parameters for condition-specific anticipatory guidance—something often lacking in handoff communication.
Known Concerns Regarding an Official Signout Note
Despite these potential advantages of an official, central, EHR-integrated signout note, some may contend that it would be better if physician signout remained “off the record.” We have found that these worries generally are due to concerns about informal team communication or are about increased liability given what is written exclusively in signout notes. To the first point, we argue that if information is important for decision making during cross-coverage, it probably should be in a patient's record. Professional ways exist to document even the most delicate information if it is relevant to patient care. There may indeed be a need for an informal channel of physician communication, but we suspect that it could be supported in better ways. For example, an electronic discussion board or secure messaging service that is not kept as part of the formal record could serve this purpose, perhaps in a more efficient or effective manner. We are actively conducting research in this area to determine the best approach to facilitate this type of informal team discussion. To the second point regarding liability, we believe it is just as likely that the information documented in signout notes could serve as evidence of good practice as it could of bad practice. The signout note is one of the most reviewed documents by the clinical team and therefore arguably one of the highest-fidelity records of the rationale behind clinical decision making.
Recommendations for the Future
We propose a sequence of two steps. First, we recommend that signout notes become part of the official medical record. We believe that this step will drive standardization of the handoff processes for which many other investigators have called. We also believe that this step will encourage commercial EHR vendors to supply a critical workflow support tool as part of their delivered products. Integrating the physician signout note into EHRs as an official, centralized document may enhance patient safety during handoff by improving data accuracy in the signout note, providing broad access to rich, yet customarily siloed data, and serving as a new vehicle for clinical decision support. We should also note that physicians are not the only clinicians conducting patient handoff, and efforts should be made to investigate whether other types of handoff documentation (e.g., nursing shift reports) should be made part of the record as well.
Second, we recommend that novel applications of information technology be investigated to enhance and safeguard the signout note's usability and its role in supporting the workflow of physicians. Because these documents are often multiauthored and of multidisciplinary interest, future designs should incorporate emerging findings from research on collaborative computing and adopt features from innovative social Web technologies (e.g., version control, author attribution, concurrent editing, etc., as in Wikipedia). These same technologies could be adapted for secure use in EHRs and be leveraged to support an informal communication channel that exists alongside, but not within, the signout note. Regardless of the specific innovations, care should be taken to preserve this working document's sequestered status from billing compliance regulations to encourage utility, saliency, and brevity.
We suggest that it is time to sign off on signout notes. We suggest, that is, to make them an official part of the medical record and reap the potential benefits as we have outlined here. Not only will this support and potentially enhance clinical care but it also will provide researchers with the infrastructure, standardization, and tools necessary to conduct the robust studies to discover evidence-based solutions for safe and efficient patient handoff. Such knowledge would allow us to educate our physician trainees on how to optimally conduct a critical patient safety activity.
The authors thank the members of the Clinical Communication, Collaboration, and Documentation Lab in the Department of Biomedical Informatics at Columbia University College of Physicians and Surgeons, with special thanks to David Vawdrey and Matthew Fred.
This commentary reflects the views of the authors and does not represent the position of NewYork-Presbyterian Hospital or Columbia University College of Physicians and Surgeons.
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