Integrating physician sign-out with the electronic medical record
integrating physician sign-out with the electronic medical record.25. Sarkar U, Carter JT, Omachi TA, Vidyarthi AR, Cucina R, Bokser S, van Eaton E, Blum M. J Hosp Med. 2007 Sep;2(5):336-42
SynopSISis a tool that is used mainly to compile and organize information from the electronic medical record to support hospital discharge, daily provider decisions and overnight or cross coverage decisions. It reflects the provider’s- patient care and daily work-flow needs.
2006 National patient safety goals, the joint commission on accreditation of health care organization JCAHO requires that each hospital implement a standardized structured approach to transfers of care.
Transfers of care have shown to be a source of medical error. Ad hoc systems have been created by providers separate from the chart, designed to track a patient’s progress over time and to facilitate transfers of care. These sign-out systems range in complexity from simple handwritten index cards to adapted spreadsheets, PDA systems. Those ad-hoc systems are not standardized, resulting in content and accuracy that vary among providers. These systems may fail to identify critical elements of a patient condition, promoting ineffective communication and placing the patient at increased risk of adverse events.
SynopSIS is integrated with hospital’s EMR, it provides an at a glance screen of the patient’s current condition. A problem list is entered by the primary hospital physician. The Anticipated problem/To do list supports the sign-out function from which providers can coordinate care related activities and make contingency plans for anticipated events. This screen is editable by physicians. Data may be removed as their importance lessens or as the patient’s condition changes. Deleted data are saved in the medical record and are viewable by audit.
A study was conducted in a tertiary university based teaching hospital with 2 campuses at the university of California, San Francisco, Medical Center (UCSFMC), to evaluate synopSIS impact on communication between care teams, quality of sign-out, patient continuity of care and rounding efficiency.
The study showed that quality of care will improve with synopSIS , providers can assume care of an unfamiliar patient, increase time with patients during rounds and allow more education time for trainees.