Enhancing continuity and safety in critical care: Through effective documentation and structured handover

Lalitha1, Gowtham2

1ICU Supervisor, Kauvery Hospital, Marathahalli

2Nursing educator, Kauvery Hospital, Marathahalli

Abstract

Effective documentation and structured handover are vital for ensuring patient safety, enhancing the continuity of care, and supporting clinical decision-making in critical care settings. This report summarizes best practices in CCU documentation and communication strategies, emphasizing the integration of electronic medical records (EMR), the ISBAR communication tool, and structured assessment frameworks like FAST-HUG-BID and DOMITE POSTER.

Introduction

Documentation in Critical Care Units (CCU) refers to any written or electronically generated record that describes a patient’s condition and the services provided. As stated, “If it wasn’t documented, it wasn’t done.” This principle underscores the legal, ethical, and clinical importance of accurate and timely records.

Objectives of Documentation

  • Emphasize the importance of proper documentation in ICU.
  • Describe various types of records used in critical care.
  • Highlight the use and advantages of EMRs.
  • Address legal considerations associated with medical records.

Principles of Effective Record Writing

  • Continuous writing with no blank spaces; if present, must be struck through, dated, and signed.
  • Patient identification on every page.
  • Use of standardized abbreviations only.
  • Truthful, concise, and comprehensive entries.
  • Inclusion of all services and interventions provided.

Benefits of Accurate Documentation

  • Supports quality care and treatment planning.
  • Aids in continuity of care and communication among caregivers.
  • Acts as a reminder system for ongoing and future interventions.
  • Provides a legal safeguard for healthcare providers.

Types and Components of CCU Documentation

Types

  • Handwritten notes.
  • Computer-based systems or hybrid models.

Components

  • Medical and nursing records
  • Medication and lab charts
  • Consent and transfer forms
  • Care bundle checklists (VAE, CLABSI, CAUTI, SSI)
  • Blood transfusion records, end-of-life forms, restraint and ADR forms
  • Electronic Medical Records (EMRs)

Advantages

  • Easy access to patient history.
  • Reduced errors from illegible handwriting.
  • Enhanced data security and accessibility for patients.
  • Better tracking of treatment progress and clinical decisions.
  • ISBAR Framework for Handover

A structured approach to communication, ISBAR ensures accuracy and clarity in handovers:

I – Identification/Introduction: Present yourself and identify the patient with necessary details.

S – Situation: Describe the current clinical status and interventions.

B – Background: Provide relevant medical history and context.

A – Assessment: Share recent findings and diagnostic results.

R – Recommendation: Communicate care priorities and next steps.

Aim: To standardize communication, foster team coordination, and ensure effective information transfer.

FAST-HUG-BID Checklist

This mnemonic enhances daily patient assessment:

  • F: Feeding
  • A: Analgesia
  • S: Sensorium/Sedation
  • T: Thromboembolic prophylaxis
  • H: Head elevation
  • U: Ulcer prophylaxis
  • G: Glycemic control
  • B: Bowel movement
  • I: Indwelling catheter assessment
  • D: Drug de-escalation

It promotes a holistic view of patient care and prevents omissions.

Alternative Documentation Tools

  1. DOMITE:
  • D: Devices (e.g., ventilators, monitors)
  • O: Observation of surgical site
  • M: Mouth care
  • I: IV fluids
  • T: Tube care
  • E: Eye care

2. POSTERSS:

  • P: Positioning
  • O: Oxygen therapy
  • S: Suctioning
  • T: Tube feeding
  • E: Elimination
  • R: RBS monitoring and Restraint assessment
  • S: Sedation

These frameworks ensure consistent care delivery and effective shift handovers.

Conclusion

Robust documentation and standardized handover protocols like ISBAR and FAST-HUG-BID are integral to critical care nursing. It’s very essential guidance for CCU staff to strengthen communication, promote patient safety, and maintain legal and clinical accountability through systematic recordkeeping practices.

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