LABORATORY Poor or vague Report reader may make Provide templates for REPORT, impressions of the case incorrect assumptions, common diagnoses CONSULTATION with an unclear potentially impacting Teach the learner to REPORT statement of reasons for treatment outline the key concepts the uncertainty recommendations to be transmitted before Delays in treatment writing the draft report Requests for second opinion via clinician Incomplete report Delayed treatment Rather than rely on (missing parameters) Requests for review of electronic synoptic case (duplication of work) reporting systems, the learner may write a draft report, including all necessary parameters Encourage reference to College of American Pathologists’ cancer reporting protocols for draft writing Incorrect use of language Improper grammar and Provide a list of Use of non-conventional ambiguities may lead to standardized terminology reader misunderstanding (conventional) of the severity of findings terminology Delays in treatment Teach the learner to Requests for review of outline the key concepts case (duplication of work) to be transmitted before writing a draft Abbreviations used Using abbreviations that Teach the learner to look SURGICAL – OPERATIVE without citing specifics are not known can result up and record the REPORT (e.g. AVSS) in misunderstanding of appropriate specific Missing pertinent patients needs and / or pertinent vitals (HR, BP, information (e.g. delaying further SaO2, Temp, urine intraoperative findings, intervention or alterations output) blood loss, placement of in management due to Teach the learner to ask drains, pathology confusion for and record the pending, intraoperative Missing information that various important complications can direct and alter surgical aspects experienced, etc.) care, the learner to Incorrect or incomplete investigations, or clearly label and record procedure recorded monitoring positions of drains (use Incorrect drains, etc., diagram if necessary) may be removed the learner to (especially in cases of discuss procedure multiple drains) performed with MRP so Perception of patient that it can be adequately having undergone reported in the chart incorrect procedure leads to miscommunication with the patient, family, and consultants, and
LABORATORY REPORT, CONSULTATION REPORT Poor or vague impressions of the case with an unclear statement of reasons for the uncertainty Report reader may make incorrect assumptions, potentially impacting treatment recommendations Delays in treatment Requests for second opinion via clinician Provide templates for common diagnoses Teach the learner to outline the key concepts to be transmitted before writing the draft report Incomplete report (missing parameters) Delayed treatment Requests for review of case (duplication of work) Rather than rely on electronic synoptic reporting systems, the learner may write a draft report, including all necessary parameters Encourage reference to College of American Pathologists’ cancer reporting protocols for draft writing Incorrect use of language Use of non-conventional terminology Improper grammar and ambiguities may lead to reader misunderstanding of the severity of findings Delays in treatment Requests for review of case (duplication of work) Provide a list of standardized (conventional) terminology Teach the learner to outline the key concepts to be transmitted before writing a draft SURGICAL – OPERATIVE REPORT Abbreviations used without citing specifics (e.g. AVSS) Missing pertinent information (e.g. intraoperative findings, blood loss, placement of drains, pathology pending, intraoperative complications experienced, etc.) Incorrect or incomplete procedure recorded Using abbreviations that are not known can result in misunderstanding of patients needs and / or delaying further intervention or alterations in management due to confusion Missing information that can direct and alter care, investigations, or monitoring Incorrect drains, etc., may be removed (especially in cases of multiple drains) Perception of patient having undergone incorrect procedure leads to miscommunication with the patient, family, and consultants, and Teach the learner to look up and record the appropriate specific pertinent vitals (HR, BP, SaO2, Temp, urine output) Teach the learner to ask for and record the various important surgical aspects the learner to clearly label and record positions of drains (use diagram if necessary) the learner to discuss procedure performed with MRP so that it can be adequately reported in the chart
Communicator_T7%20Coaching_Resident%20coaching%20on%20common%20written%20communications.docx