Evaluation of Computerized Free Text Sign-Out Notes: Baseline Understanding and Recommendations

Area of Science:

• Healthcare Informatics
• Patient Safety
• Clinical Communication

Background:

• Standardized sign-out is crucial for patient safety, aiming to improve communication and reduce errors during shift changes.
• Computerized systems with free text entry offer flexibility but lead to varied sign-out note content.
• A systematic exploration of content generated by users of computerized sign-out systems is lacking.

Purpose of the Study:

• To systematically explore the range of content generated by clinicians using computerized sign-out systems.
• To determine how clinicians record standardized sign-out information in a system with free text and limited structure.

Main Methods:

• Qualitative analysis of free text sign-out notes.
• Review of 730 patient cases across 39 hospital units at an academic medical center.

Main Results:

• Two primary categories of information expression emerged: patient treatment (summaries, awareness, action items) and care team coordination (discharge, contact, social concerns).
• A third category, presentation of information, also emerged.
• While information varied in location and structure, some units demonstrated relatively standardized sign-out note content.

Conclusions:

• Computerized free text sign-out notes synthesize data from various sources.
• Findings establish a baseline understanding of current sign-out note content.
• Formalizing unit-specific standardization and system use patterns is recommended to reduce variability and enhance communication.