Transcript Signouts - Case Western Reserve University

Sign outs
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Good communication is essential and
critical for appropriate patient care
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Difficult to master the technique to include
all pertinent information in a concise
manner
Process not uniform
More “handoff’s” due to duty hour
restrictions
Patient Hand Off Tool (HOT)
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Used by most services in the hospital
for communication and sign out
Prepared by the primary team but can
be edited by any service/consultant
Intern nightfloat will have a copy of the
HOT on each patient
Sign out Process
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Should be done in a quiet place with
the least number of distractions
possible
Start with your sickest patient
Make sure ALL your patients are
included!
Sign Out Process
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S- sick and code status
I- ID statement
G- General hospital course
N- new events
O- overall health status
U- upcoming events/possibilities
T- “to do” overnight
Discharge Summaries
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Are dictated at UH; typed at VA
Must be done DAY OF DISCHARGE
Tag a day of discharge progress note at
end to save you time
Thorough yet not too lengthy!
How To Dictate
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Dial 66000 in house
Dial (216) 286-6000 from outside
Physician ID #
1#
7#
Medical Record Number #
“begin dictation”….
How To Dictate
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“This is Dr. x dictating discharge summary for patient x MR number
xxx”
Date of Admission; Date of Discharge
Attending on service
Discharge Diagnosis
Procedures performed
HPI/Hospital Course
Discharge medications*
Follow up appointments
follow up items
Condition and disposition at discharge
Day of discharge progress note
copies of dictation you want sent
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PCP, Consultants
How To Dictate
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Important Keypad numbers
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5 is pause
2 is to resume
9 for confirmation number
Remember to divide paragraphs
Can be amended
Can be done from home
Questions