Summary
Background: Standardization of sign-out, the transfer of patient information and responsibility
between inpatient providers at shift change, is a Joint Commission National Patient
Safety Goal intended to improve communication and reduce risk of error. Computerized
systems with free text data entry and limited structure allow clinicians to generate
sign-out notes in a variety of ways.
Objective: The literature lacks a systematic exploration of the range of content generated by
users of computerized sign-out systems. The goal of this study was to determine if
and how clinicians record standardized sign-out information using a system with free
text data entry and limited structure.
Methods: Using qualitative methods, we reviewed free text sign-out notes for 730 patient cases
across 39 hospital units at an academic medical center.
Results: Two categories of information expression emerged from analysis: patient treatment—
comprised of patient summaries, awareness items, and action items—and care team coordination—
consisting of discharge information, contact information, and social concerns. A third
category describing the format of sign-out note content, presentation of information,
also emerged. Location and structure of information varied, but sign-out note content
for some hospital units exhibited specific characteristics and was relatively standardized.
Conclusion: Findings provide a baseline understanding of computerized free text sign-out note
content. Sign-out notes contained a synthesis of data from disparate sources. We recommend
formalizing existing unit-specific content standardization and system use patterns
to reduce sign-out note variability and improve communication.
Keywords
Evaluation - continuity of patient care - hospital information systems - patient care
team - qualitative research
