Processes for effective communication

Healthcare services in primary and community settings often see patients on a regular basis and establish rapport and professional relationships over extended periods of time. However, where healthcare providers are unfamiliar with a patient, or in certain high-risk scenarios, patient identifiers should be used to help ensure correct care is delivered. 

Patient identifiers are items of information that can be used to confirm a person’s identity. There are a range of patient that can be used. Some examples may include: 

• Legal name
• Preferred or affirmed name
• Date of birth
• Sex
• Gender
• Address (including postcode)
• Healthcare record number
• Last three digits of a patient’s phone number. 

Healthcare services should determine patient identifiers that will be most appropriate in their service context and consider the privacy implications when adopting a particular method. Using at least three patient identifiers reduces the risk of incorrect identification.^[i]

When patients are known to the healthcare service, periodic confirmation of identity may be appropriate, for example, ‘Do you still live at… I’d like to check that we have the correct details on record’. 

Links to Action 3.26 Processes for effective communication

• How does the workforce confirm a patient’s identity before providing care? 
• What patient identifiers are used to confirm the identity of a patient?

• Define a process for the reliable and correct identification of patients when health care, medicine, therapy and other services are provided.
• Agree a list of patient identifiers that can be used by the workforce.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• A documented process for patient identification
• Documentation on the agreed patient identifiers to be used
• Observation of the patient and procedure matching process 
• Templates, checklists or documentation identifying and matching a patient to their intended care, for example, patient registration forms and healthcare records
• Communication materials or training records for the workforce on correct patient identification.

Commission resource

• Communicating for safety resource portal – provides practical support for implementing the communicating for safety actions in the NSQHS Standards. Resources are therefore primarily relevant in acute settings; however, the principles and strategies outlined in these resources are broadly applicable.

Other resource

• Australian Bureau of Statistics: Standards for Sex, Gender, Variations of Sex Characteristics and Sexual Orientation Variables – developed to support the standardisation of the collection and dissemination of data relating to sex, gender, variations of sex characteristics and sexual orientation. 

Healthcare services should correctly match a patient to their care. This process should occur at occasions that require three approved identifiers to be used. These are: 

• When a patient is unknown to the healthcare provider 
• Before health care is delivered 
• When making a referral to another healthcare provider. 

Essential information in a patient’s healthcare record 

Documentation is an essential component of effective communication. Given the complexity of health care, healthcare records are among the most important information sources available to healthcare providers. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. This can lead to a loss of information, which can result in misdiagnosis, errors and patient harm.

Documentation can be paper-based, electronic or a mix of both. It can also take several forms, including the referrer’s information, care plan, referrals, checklists, test results, notes and discharge or transition of care summaries. For this action, services are required to have in place systems to ensure that essential information about a person’s care is documented in the healthcare record. For documentation to support the delivery of safe, high-quality care, it should: 

• Define when documentation is required 
• Be clear, legible, concise, contemporaneous, progressive and accurate 
• Include information about assessments, action taken, outcomes, reassessment processes (if applicable), risks, complications and changes
• Meet all necessary medico-legal requirements for documentation, such as record retention timeframes, date and time or author’s name and designation
• Ensure healthcare providers know how to gain access to the healthcare record, the healthcare service’s templates, checklists or other tools and resources that support safe, high-quality documentation. 

What does high-quality documentation look like?

Regardless of the medium (paper or digital), high-quality documentation should follow the same guiding principles as outlined in Table 5.

Table 5: Guiding principles for high-quality documentation

• Source: Amended from Documenting information, Communicating for Safety resource portal (ACSQHC, 2022).

Links to Actions 1.11, 1.12 Healthcare records and 3.25 Processes for effective communication

• In your healthcare service when do you need to match patients to their health care and what processes are used? 
• What documentation does your healthcare service require in the patient’s healthcare record? 
• What processes are in place to ensure that your patients’ healthcare records are accurate and complete?
• How are healthcare records accessed by all those involved in the patient’s care? 

• Develop and implement processes to correctly match patients with their intended health care using defined patient identifiers.
• Ensure that your healthcare service has relevant, accurate, complete and up to date information about patients’ care documented in their healthcare record.
• Ensure that patients’ healthcare records are available and accessible to those involved in their care.

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include: 

• Documents that describe how patients are matched to their care
• Communication materials or training records that demonstrate the workforce has been educated on the relevant protocol for correctly identifying a patient 
• Observation of healthcare records where the information used to identify a patient and match them to their care is documented
• Observation of healthcare records being available to clinicians at the point of care.

Commission resources

• Communicating for Safety resource portal – provides practical support for the implementation of the communicating for safety actions in the NSQHS Standards. The principles and strategies outlined in these resources are broadly applicable. 
• NSQHS Standards User Guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium – provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the NSQHS Standards. The principles and strategies outlined in this resource are broadly applicable. 
• Recommendations for terminology, abbreviations and symbols used in medicines documentation – sets out principles for safe, clear and consistent terminology for medicines, and safe terms, abbreviations and dose designations for medicines.

Other resource

• Primary Healthcare Network, Tasmania: Shared Transfer of Care – templates and tools – organised by strategies for implementing shared transfer of care.