Appendix 2Communicating in Healthcare Teams: Key Ideas

Centre for Advancement of Interprofessional Education defines Interprofessional education as “occasions when two or more professions learn with, from and about each other to improve collaboration and quality of care.” Core competencies include:

1. Describe their own professional roles and responsibilities and the general scope of practice of other health professionals to colleagues and patients/clients
2. Know how to involve other professions in patient care appropriate to their roles, responsibilities and competence.
3. Collaborate with other professions to establish common goals, provide care for individuals and caregivers, and facilitate shared decision-making, problem-solving and conflict resolution
4. Contribute to team effectiveness by sharing information, listening attentively, respecting others’ opinions, demonstrating flexibility, using a common language, providing feedback to others, and responding to feedback from others

Medicine is practiced in the context of healthcare teams, where it is important you understand roles and scope of practice of allied health professionals, and establish foundational interprofessional communication skills to further build on in clerkship.

Closed-loop communication is the process of acknowledging the receipt of information and clarifying with the sender of the communicated message that the information received is the same as the original, intended information. In essence, it is the process of confirming and cross-checking information for accuracy. This style of communication fosters the ability to ensure that the entire team has shared goals, expectations, awareness, and plan execution.

• Don’t suggest ordering the most invasive test or treatment before considering other less invasive options.
• Don’t suggest a test, treatment, or procedure that will not change the patient’s clinical course.
• Don’t miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary.
• Don’t hesitate to ask for clarification on tests, treatments, or procedures that you believe are unnecessary.
• Don’t suggest ordering tests or performing procedures for the sole purpose of gaining personal clinical experience.
• Don’t suggest ordering tests or treatments pre-emptively for the sole purpose of anticipating what your supervisor would want.

• Don’t order investigations that will not change your patient’s management plan.
• Don’t order repeat laboratory investigations on inpatients who are clinically stable.
• Don’t order intravenous (IV) when an oral (PO) option is appropriate and tolerated.
• Don’t order non-urgent investigations or procedures that will delay discharge of hospital inpatients.
• Don’t order invasive studies if less invasive options are available and as effective.

• Importance: Medical records facilitate good care; allow a subsequent caregiver to understand the patient’s condition and basis of current investigations/treatments; provides a method to communicate with other team members; satisfy legal and ethical obligations (to medical regulatory authorities) and act as evidence should care be later questioned.
• What to Document: Goal is to give an adequate picture of the clinical situation. This includes:
  • General Content Included: Patient and Source of Information; Relevant history and physical findings (pertinent +ves and -ves); Conclusions (working diagnosis, differential diagnosis, and final diagnosis as indicated); Plan of Action (Investigations, consultations/referrals, Treatment, Follow-up – and rationale for the plan); Any Information given to the patient or Substitute Decision Maker (verbal or written instructions, questions asked/answered, patient understanding of plan, consent to treatment, any refusal of care); and your signature/trainee level.
  • Timing: In a note (consult or daily note), write down the date, time start, and time end of your visit with the patient
  • Handover (e.g. Handover lists on Inpatient Units): This documentation facilitates a transfer of care (typically temporarily for the overnight team) – where the person assuming responsibility overnight doesn’t have your depth of knowledge about the patient’s condition. What do they need to know? → What do you expect to happen; what are you worried about (and what you would do if these concerns came to pass); Any pending investigations/consultations/reports; the plan of care going forward; and who will do what and for how long (i.e. start and end times/dates for transfer of care)
• When to Document: Ideally as soon as possible during or after a clinical encounter (contemporaneous notes).
  • How do you make corrections to a paper chart: Cross out information with a single line, and date and initial. The error should still be visible through the single line crossed out.
  • How do you make corrections to an electronic chart (EMR): Indicate reasons for the change and enter correct information. NEVER give out your passwords or use others’ passwords.
  • NEVER make a correction or modify the chart (paper or electronic) after learning of a complaint or legal action.

• S: Subjective (Hx) – patient reported
• O: Objective (Px) – what you found
• A: Assessment (DDx)
• P: Plan (Ix, Tx, overall impression based on your DDx)

• Note: Admission orders are increasingly becoming standardized electronic forms, meaning the ADDAVID approach may not be as relevant moving forward. That said it still provides a solid foundation.

Admission Orders

• CODE STATUS
  • What would the patient want if they became critically ill while in hospital?
  • Full Code, DNR (Do Not Resuscitate), AND (Allow Natural Death)
• Allergies
  • NKDA (No Known Drug Allergies), etc.
• A: Admit
  • Admit to __________ under Dr. __________
• D: Diet
  • NPO: None P/O; Healthy Diet; Diabetes Diet; ↓ Na⁺ Diet (CHF)
• D: Diagnosis
  • Working diagnosis
• A: Activity Level
  • AAT: Activity as Tolerated; Non-Weight Bearing
• V: Vitals:
  • Monitoring Frequency: Q4, Q6, Q8, QSHIFT (= 12)
  • Telemetry: EKG real-time monitoring, not recorded ↔ Halter: 24-48 hr EKG recorded, read later
• I: Investigations + IVs
  • Note: This will be multiple lines on your orders
  • Examples: Normal Saline 100 CC/hr; Saline Lock IV (No volume, line in place)
• D: Drugs + DVT Prophylaxis
  • Note: This will be multiple lines on your orders
  • Examples: Continue (Drugs from home, etc.); Hold; Start
  • Housekeeping: DVT prophylaxis, consider Tylenol PRN order as good practice

Case Report

Prepared by: Student Name, Year 1 Medical Student, McMaster, Date, Time Start and Time End.

ID: Ms. Smith is a 40-year-old female.

GOC: Full Code

CC: The patient presents with fatigue, weakness, headaches, vision changes, unintentional weight gain, easy bruising, and diaphoresis at rest, polyuria, and polydipsia.

HPI: The patient’s current set of symptoms began 6 months ago. During this time, she reports developing a continuous unfluctuating sense of fatigue. This change is a deviation from the normal baseline for the patient, who reports having a high-energy level. She attempted lifestyle management strategies to alleviate fatigue, including addressing stress levels at work, sleep cycles, exercising twice per week, and eating according to the Canada Food Guide – none of which improved her fatigue. With respect to weakness, the patient particularly reports difficulty maintaining balance especially while climbing stairs. The patient has begun to experience regular weekly headaches that localize to the frontal lobes bilaterally and resolve with ibuprofen. The patient’s peripheral vision has become blurred. Her unintentional weight gain is localized to three areas – rounding of the face, a hump on the upper back, and her abdomen is increasing in size as she has to buy bigger size pants despite losing weight. In addition, she reports purple striae developing around the abdomen that has darkened with time. The patient reports bruising easier than normal and sweating at rest. She also reports polydipsia, nocturia, no dysuria, and urine that is notably clear indicating adequate hydration status.

PMHx:

• Illness: The patient has an overactive bladder that is well-controlled with medication, and a history of Urinary Tract Infections. The patient has Type 2 Diabetes Mellitus, Hypertension and Osteoarthritis; each is well-controlled with medication.
• Surgeries: No history of surgeries
• Hospitalizations: No previous hospitalizations. Patient sees family doctor on a regular basis. No specialists involved in the care of this patient.

Allergies: The patient has no known drug allergies.

Medications: The patient takes Detrol (2 mg, Per Oral, Twice Per Day) for Bladder Control; Metformin (1000 mg, Per Oral, Twice Per Day) and Glyburide (5 mg, Per Oral, Twice Per Day) for her Type-2 Diabetes Mellitus; Atenolol (50 mg, Per Oral, Once Per Day) and Norvasc (5 mg, Per Oral, Once Per Day) for her Hypertension; and Tylenol #3’s (Per Oral, as Per Needed) for pain management of her Osteoarthritis. The patient does not take any Over-The-Counter Drugs except ibuprofen for headaches and does not take herbal supplements.

Social History: Ms. Smith is a nurse, living with her husband who works as an accountant and her daughter. She does not report difficulty supporting herself financially. She is sexually active with her husband only. The patient has never smoked, does not drink alcohol, and has no history of illicit drug use.

Family History: Ms. Smith’s family has no history of Type-2 Diabetes Mellitus, Cancer, or Cardiovascular Disease

Functional Inquiry: NOTE: INCLUDE ONLY THOSE THINGS THAT DO NOT APPEAR IN THE HPI BUT WERE ASKED - no need to duplicate

• General: Patient experiencing no loss of appetite, fever, night sweats or chills. Patient is fatigued, and experiences weakness particularly in legs
• Dermatological: Patient reports no rashes
• Head and Neck: Patient has had no changes in hearing, no nosebleeds, mouth ulcers, or throat pain
• Respiratory/CV: Patient does not report shortness of breath, coughing, or experiencing chest pain or palpitations
• GI: Patient has not experienced nausea, vomiting, diarrhea, constipation or change in bowel movements – movements are soft and once per day
• Genitourinary: Patient has noticed clearer urine, and nocturia. Patient’s last menstruation was 2.5 weeks ago; menstruations usually occur monthly
• Endocrine: Patient is not experiencing heat intolerance
• MSK: Patient experiences joint pain and swelling due to osteoarthritis
• Lymphatics: Patient reports bruising easily, with no new lumps or bumps except for fat pad in upper back.
• Neurological: Patient has not experienced numbness or tingling
• Psychiatric: Patient is frustrated due to her chronic fatigue

Summary: Ms. Smith is a 40-year-old female patient, who has a history of type-2 diabetes mellitus, urge incontinence, hypertension and osteoarthritis, who presents to the clinic with fatigue, weakness, headaches, vision changes, unintentional weight gain, easy bruising, diaphoresis at rest, polyuria, and polydipsia. This set of symptoms had an acute onset 6 months ago, has been resilient to patient-directed lifestyle management measures and has not improved since onset.

Impression & Plan: The differential for these signs and symptoms includes etiologies of elevated glucocorticoids suggestive of Cushing’s Syndrome. Possible etiologies include both exogenous glucocorticoid administration (as immuno-suppressant or anti-inflammatory), as well as endogenous cortisol elevation due to a deviation from normal Hypothalamic-Pituitary-Adrenal Axis (both dysregulation in any of these glands, as well as an ectopic cortisol- or ACTH-secreting adenoma). Given patient’s knowledge of medications, exogenous corticoid administration is low on differential and diagnostic efforts should be focused on ruling out endogenous sources of glucocorticoid production. Our plan will include:

1. Visual Field Test – to help determine extent of peripheral vision loss. If characteristic of optic chiasm compression, raises suspicion of pituitary adenoma.
2. CBC and Serum Blood Tests – including Glucose, K+, HCO3, Triglycerides, LDL/HDL, INR. 24-hour urinary cortisol should be measured at 8 AM, along with plasma ACTH. Special instruction should be given to patient as she has diabetes.
3. Dexamethasone Suppression Test – to assess whether an endogenous cortisol elevation is occurring due to defects at level of pituitary or level of adrenal cortex.
4. Imaging – to identify possible adenomas/carcinomas secreting cortisol or ACTH of the brain and abdomen.
5. Follow-up with patient for next steps, including possible referral to a surgeon for trans-sphenoidal resection should all test results together rule-in an ACTH-secreting adenoma at level of pituitary.

_________________
Student Name, Medical Student Yr 1

• Phone Dictation Systems: Remember a transcriptionist turns your phone report into a formal document – speak clearly and spell any unusual medical terms or medications (transcriptionists receive training, spelling helps get it right first time).
  • Verbalizing Punctuation: In phone dictations, it’s vital you verbalize the punctuation you’re using. The ones necessary to use for the template are highlighted in red
  • Verbalizing “New Line”: For lists of diagnoses, lists of medications, and follow-up lists, etc.
• Who to send copies to: Family doctor; Attending on inpatient service; outpatient physicians in circle of care
• Course in Hospital: Important to be concise– remember your dictation will be referenced the next time patient presents.

• [Today’s Date]
• This is [spell your name] dictating a discharge summary for Dr. [Attending] ([Attending’s Discipline]) Dictating on [Patient name] record number is [state number]. Copies of this report to [Family Doctor’s name] (GP), [Attending’s Name] ([Attending’s Discipline]), [others]
• Admission Date: [Date of admission]
• Discharge Date: [Date of discharge]
• Discharge Diagnosis: [State Most Responsible Diagnosis affecting length of stay]
• New Paragraph, New Heading
• Other Diagnoses:
• New Paragraph, New Heading
• Pre-Admission Diagnoses:
  1. [PMHx comorbidity 1]
• Post-Admission Diagnoses:
  1. [Additional diagnoses after admit]
• Post-Admission Diagnoses:
• New Paragraph, New Heading
• Discharge Medications:
• Medications on Admission: 2. [Medication name, Dose, Route, Frequency] – [Length of Rx given vs. Continue Home Supply], [Number of Repeats]
• Medications Added:
  1. [Medication name, Dose, Route, Frequency] – [Length of Rx given vs. Continue Home Supply], [Number of Repeats]
• Medications Changed:
  1. [Medication name, Dose, Route, Frequency] – [Length of Rx given vs. Continue Home Supply], [Number of Repeats]
• Medications Discontinued: 4. [Medication name, Dose, Route, Frequency] – [List reason why the medication was discontinued]
• New Paragraph, New Heading
• Course in Hospital: [Include relevant hospital investigations: CXR, Echo, VQ scans, CT scan, U/S, Endoscopy, Stress Tests, EKG, most recent Hb, Cr, TSH, B12, best FEV1 & FVC]
• New Paragraph, New Heading
• Follow-up:
  1. [Doctor 1] ([Doctor 1’s Discipline]) in [Number of weeks/months]
  2. [Outpatient care]
  3. [Outpatient tests – list who should follow-up on these results]
• New Paragraph, New Heading
• Dr. [Attending] ([Attending’s Discipline]), [Your Name and Status] dictating for Dr. [Attending]
• Time In: [Time] – Time Out: [Time]; End of dictation