Communication, Documentation, and Care Coordination
Structured Communication
Use standardized handoff tools such as SBAR (situation, background, assessment, recommendation) for provider communication and shift reports. Closed-loop communication - the receiver repeats back the order - prevents error, especially for verbal and telephone orders. Use teach-back to confirm patient understanding rather than asking "do you have questions?"
Documentation Standards
Chart objectively, contemporaneously, and completely: what was observed, what was done, the patient's response, and who was notified. Avoid subjective judgments, opinions, and late entries presented as timely. Never alter a record; correct errors with a single line, date, time, and initials. Document refusal and education provided. If it was not documented, the legal presumption is that it was not done.
Care Coordination
Coordination spans interdisciplinary teams, transitions of care, and discharge planning. Medication reconciliation at every transition reduces adverse events. Identify barriers - health literacy, transportation, cost, language - and involve interpreters and case management. Culturally congruent communication improves adherence.
Traps
Questions may offer "document the finding" when the priority is to notify the provider first, or offer a vague handoff lacking a recommendation. Watch for answers that use family members as interpreters for consent discussions, and for discharge teaching delivered without teach-back verification.
Worked Example
A patient's oxygen saturation drops to 86 percent. The correct sequence is: intervene and reassess, notify the provider using SBAR with a clear recommendation, then document the event, the notification, and the response. Documentation follows action, not the reverse.