Documentation, Reporting, and Communication of Changes
Domain 5 tests objective documentation, timely escalation, and clear communication.
Documentation
Record date and time, procedure, patient tolerance, tracing quality, any deviation, and notification. Correct errors with a single line, date, and initials; never erase or backdate.
Communication
Use SBAR: Situation, Background, Assessment, Recommendation. Report critical changes such as a new arrhythmia, rate below 40 or above 130 with symptoms, chest pain, dyspnea, syncope, diaphoresis, or altered mental status. Use read-back for verbal reports. Follow the chain of command if no response.
Worked example
During a Holter hookup, the patient becomes pale and dizzy. The monitor shows a heart rate of 38. The technician stays with the patient, calls rapid response, and reports: Situation-symptomatic bradycardia, heart rate 38, blood pressure 80/50; Background-here for Holter; Assessment-pale and diaphoretic; Recommendation-immediate evaluation. The technician documents the time, findings, who was notified, and the response.
Traps
Documenting opinions such as probably fine; delaying escalation to finish the tracing; discussing protected health information in public; failing to document notification and read-back; altering a record.