Protocol to describe the analysis of text-based communication in medical records for patients discharged from intensive care to hospital ward

BMJ Open. 2016 Jul 8;6(7):e012200. doi: 10.1136/bmjopen-2016-012200.


Introduction: Effective communication during hospital transitions of patient care is fundamental to ensuring patient safety and continuity of quality care. This study will describe text-based communication included in patient medical records before, during and after patient transfer from the intensive care unit (ICU) to a hospital ward (n=10 days) by documenting (1) the structure and focus of physician progress notes within and between medical specialties, (2) the organisation of subjective and objective information, including the location and accessibility of patient data and whether/how this changes during the hospital stay and (3) missing, illegible and erroneous information.

Methods: This study is part of a larger mixed methods prospective observational study of ICU to hospital ward transfer practices in 10 ICUs across Canada. Medical records will be collected and photocopied for each consenting patient for a period of up to 10 consecutive days, including the final 2 days in the ICU, the day of transfer and the first 7 days on the ward (n=10 days). Textual analysis of medical record data will be completed by 2 independent reviewers to describe communication between stakeholders involved in ICU transfer.

Ethics and dissemination: Research ethics board approval has been obtained at all study sites, including the coordinating study centre (which covers 4 Calgary-based sites; UofC REB 13-0021) and 6 additional study sites (UofA Pro00050646; UBC PHC Hi4-01667; Sunnybrook 336-2014; QCH 20140345-01H; Sherbrooke 14-172; Laval 2015-2171). Findings from this study will inform the development of an evidence-based tool that will be used to systematically analyse the series of notes in a patient's medical record.

Keywords: Hospital Ward; INTENSIVE & CRITICAL CARE; Patient Transfer; Provider Communication; Textual documentation.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Canada
  • Communication*
  • Continuity of Patient Care*
  • Documentation*
  • Humans
  • Intensive Care Units*
  • Medical Records
  • Patient Handoff*
  • Patients' Rooms*
  • Prospective Studies