Communication and Documentation Tips for Ambulatory Surgery Centers

In any business, the importance of clear communication and sound record keeping practices cannot be overstated. This applies to the medical record in particular because it is the primary instrument used to:

• record patients’ clinical information 
• communicate and coordinate care among healthcare professionals 
• support billing for care 
• defend healthcare providers in court cases 

The following suggestions may help ambulatory surgery centers (ASCs) avoid pitfalls that are commonly seen in ASC communication and record keeping practices.

Dictations

Physicians and other care providers often dictate records, such as progress notes or operative reports. While this solves the common problem of illegibility, it can create other problems such as inaccurate transcription: for example substituting right for left, missing decimal points on medication dosages, or even the loss of records. Providers should maintain a log or tickler for all dictation and check it periodically to ensure that all dictated notes have been received in hard copy. Upon receipt of the note, the content should be validated before it is signed. This can only be accomplished by reviewing it in its entirety, then signing it.

Discharge Notes

The final entry in a patient’s record should be made upon their exit of the facility. It should document an accurate and complete picture of their condition.

Important information to record includes:

• time of discharge 
• vital signs, including notations regarding significant variations from baseline 
• physical and emotional condition, pain scale, and wound condition 
• the method of discharge — wheelchair, crutches, etc., and the responsible party 
• written medication reconciliation 
• written discharge instructions 
• follow up information

Standing Orders

Physicians often provide ASCs with preprinted standing order sheets. While this practice may be efficient because deviations are infrequent, each and every one needs to be reviewed to be sure it has been customized for the individual patient. At a minimum, the form must document the patient’s name, date of birth or social security number, and allergies. Each individual order listed should have a corresponding check box for the physician to choose yes or no, rather than crossing out those to omit, and the form should be signed by the ordering physician. All forms should be reviewed and updated on an annual basis.

Template Operative Notes

Similar to standing orders, surgeons may also develop prewritten, “canned operative reports” for procedures that are frequently performed. The risk of this practice lies in the lack of customization after each procedure. Following all procedures, the surgeon should review the prewritten report in its entirety and sufficiently edit it, before validating its contents by signing it.

Specimen Logs

Lost specimens or inconsistent lab reports can be the cause of financial loss and emotional distress. ASCs have a responsibility to track specimens and ensure that the reports are received by appropriate providers. ASCs may facilitate this by using a specimen log. Each specimen should be entered into the log as soon as it is removed from the operating room (OR). The entry should include the type of specimen, diagnosis, the lab it is sent to, the method of delivery, and the time it leaves the ASC. Lab and pathology reports should be reconciled with the entries in the specimen log. Diagnostic discrepancies should be discussed with the surgeon and be tracked and trended. The log should also be reviewed at regular intervals to ensure that reports for all specimens have been received.

Telephone Conversations

Reporting a patient’s conditions to physicians and receiving orders from them is an integral part of the daily routine in ASCs. Staff should be encouraged to be both assertive and precise in their communications with physicians. While JCAHO (Joint Commission) accreditation standards require nurses to read back verbal orders, safe practices do not stop there. ASCs might also consider implementing communication methods and tools to assist staff in comprehensive, yet concise, communication with physicians.

One such method is “SBAR” — situation, background, assessment, and recommendation. It is a communication technique that was developed at Kaiser Permanente of Colorado to provide a memorable, focused framework for conversations, particularly communication of critical situations. The SBAR technique can be used to develop sample scripts, communication algorithms, and documentation templates.

Documentation of telephone calls should include:

• the date and time of the calls 
• the number of attempts that have been made 
• to where the calls were made (the physicians office, pager, answering service) 
• to whom the information was given (directly to the physician or to office staff) 
• the specific information provided (vital signs, physical condition, pain, etc.) rather than “patient status”
• orders received 

All providers and staff should know and follow a center’s policy and procedures for documentation, not just in the areas discussed above. Including medical record reviews as a part of a center’s quality or performance improvement process is an effective way to minimize an ASC’s risk. 

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