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Nurses’ notes and communication
An article for physicians by physicians
Originally published December 2000 / Revised April 2008
IL0040-3-E

Of interest to all physicians

Many letters and discussions were generated by the article on the importance of inter-specialty communication in the January 2000 Information Letter. The general concerns were:

• physicians do not have the time to read nurses’ notes;
• nurses’ notes lack focus;
• nurses’ notes themselves are poor sources of information; and
• there are better ways of communicating.

Practicing physicians well recognize the problems in relying on written notes to share information. While more direct communication may be preferable, it is not always possible. It is not the method of communication but the fact it takes place that helps all members of the medical team to provide appropriate care. Unfortunately, without documentation it is more difficult to demonstrate that communication has occurred. Thus a nurse’s note, placed where a physician should be able to see it, may be considered by the courts as evidence that the nurse has fulfilled his/her duty. Acknowledgement of the nursing note, either through a notation in the medical record or appropriate order, would likely lead a court to conclude the physician had considered the information.

Nurses and other health care professionals are trained to document their observations and their efforts to communicate with physicians, including noting when they have called the physician. Physicians should be equally careful to note what information they receive. Anything documented at the time of, or soon after, an event is far more likely to be accepted as accurate than the patient’s, physician’s or nurse’s memory of the event long after an adverse outcome has occurred.

Personal discussion with the supervising or attending nurse, notes on a communication board, in a physician’s booklet or handheld device, or any other form of communication should be documented, along with the physician’s evaluation of that information and any actions proposed or taken.

Equally important is informal discussion between two or more physicians looking after the same patient. Much of this occurs in the physicians’ lounge or hospital corridor and sometimes decisions are made based on that discussion. Following an unexpected outcome, there may be questions about what communication took place. A brief note in the chart takes time, but may save much grief in the future.

When all is said and done, good patient care does depend on good communication among all members of the team. The exact method of communication is not important, but when questions later arise, it may be vital to demonstrate that the communication occurred, as well as the content of the exchange.