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Fundamental Communication Protocols

SOAP being presented at the bedside.

SOAP being presented at the bedside.

Just as in any sport it is critical to have mastered the fundamentals: passing motion, shooting motion, blocking technique etc. Similarly physicians need to be well versed in how to communicate accurately and succinctly. Excessive detail, poor organization, long pauses, and mumbling all result in inefficient communication. To help everyone who is listening, and to help the presenter develop good habits, specific communication protocols should be followed for presenting unexpected events, progress reports and for presenting new admissions.

SBAR (For Signouts, Unexpected Events or Complications) (Very brief)

  • Situation: What complication has occurred. Example: Mr. Jone’s developed chest pain overnight that was left substernal, sharp and radiated down his left arm.
  • Background: Describe underlying conditions, his original reason for hospitalization. Example: Mr. Jones was hospitalized for hyperglycemia and mild diabetic ketoacidosis. he has received 10 Liters of fluid over 24h.
  • Assessment: What do you think is going on. Example: Mr. Jones may have received excessive fluids. On exam I hear rales half way up both posterior lung fields, his heart rate is elevated at 120 and he has jugular venous distension. I suspect his chest pain is due to cardiac ischemia resulting from increased cardiac work because of CHF.
  • Recommendations:  What diagnostic tests and therapies  should be initiated. Example: Diagnostically I have ordered a STAT CXR, cardiac enzymes and an EKG. I have also contacted cardiology. Treatment: I have ordered 40 mg of Lasix iv STAT, initiated nasal oxygen and sublingual nitroglycerin. Should we consider iv heparin at this stage?
  • Always Close the loop: When signing out a patient using SBAR, it is important that the person listening repeat the key elements to assure the presenter that he or she fully understands the sign-out.

Work Rounds Presentation (Duration of presentation < 5 min)

Because electronic records are available, the attending should review all notes prior to work rounds so that he or she is familiar with the events of the last 24 hours. The house staff’s presentations need only to emphasize the key points. When possible present in the room and have the patient describe their complaints overnight. (Note: HIPPA allows presentation even in a two-bed ward as long as the curtain is drawn, but avoid highly sensitive terms such as HIV or sexually transmitted diseases)  See Game Films for an ideal SOAP presentation.

Use a SOAP format

  • S – Subjective complaints      What are the patients active complaints today. When possible the intern can allow the patient to present their complaints (Remember the patient is the team owner).
  • O – Objective findings
    • Vital Signs (give P, BP, Resp and Temp on every patient, give the most recent values, not a range, also give any excessively high or low values during the past 24h)
    • Positive physical findings (Focus on findings related to the patients active complaints. If there has been no change since the day before simply say no change in physical findings.
    • Pertinent Test findings:
      • Abnormal laboratory findings:* Usually include CBC, Electrolytes
      • Results of Imaging studies.
  • A – Assessment (for each problem combine your assessment and plans)
      • What is your diagnosis for the patient’s problem
        • Is this problem improving, worsening, or staying the same?
        • When appropriate give your differential diagnosis
  • P – Plans
      • DX – Diagnostic
        • List blood tests
        • Radiologic tests
        • Other tests that are planned and why.
      • RX- Treatment
        • What medications are you administering for this problem
        • What other modalities are you instituting
    • Potential Discharge Issues

Bedside Checklist

Upon completion of SOAP in front of the patient the intern, nurse, team resident or attending should go through the bedside checklist using the pneumonic TEMP. Fulfilling these needs is likely to improve patient well being and satisfaction with his/her care. 

T – Tubes – IV lines, foley catheter, feeding tube: are these lines necessary; can they be discontinued?

E – Exercise: Can your patient get out of bed? Is physical therapy required? Eating: Is the diet acceptable to your patient? Does it fit with their chronic illness? Sleep – Is your patient getting enough sleep? if not why not?

M – Monitoring: Does your patient require Q4H or Q8H vital signs? Can vital signs be held when you patient is sleeping? Does your patient continue to require telemetry? Does your patient require daily blood drawing?

P – Pain: Is your patient’s pain adequately controlled? Are their adjustments in pain medications that should be made? Plan: Does your patient understand the plan for the day? Have her repeat the plan to assure understanding (teach back).

Admission Oral Presentations (Duration <5 min)

Thanks to electronic records a complete case presentation is no longer necessary. The presentation should focus on the key points (do not read the admission note verbatim) and spend the majority of time on your impressions and your diagnostic and therapeutic plans. 

  • Do include Age, sex, race, job
  • Chief Complaint: What brought the patient into the hospital. Duration of the complaint or complaints
  • Present illness:Use a Time line.Mr L. has suffered with X disease for 10 years, but was doing well until- 10 Days PTA x complaint- 7 Days PTA additional complaints or symptoms worsening

    – Day of admission – x symptom caused him to seek medical attention

    – Include review of system both positives and negatives pertinent to the chief complaint

    – Include PMH pertinent to the present complaint

    – Include PSH pertinent to the present complaint

  • FH: if not relevant to the PI say noncontributory
  • SH: habits, where do they live, what job do they have, other epidemiologic facts if pertinent to the PI
  • Allergies
  • PE: (For the first presentation it is preferred to give a head to toe PE)
    • Vital Signs Pulse, BP, Resp, Temp
    • HENT
    • Neck
    • Lungs
    • Heart
    • Abdomen
    • Extremities
    • Neuro exam
  • Laboratory findings
    • CBC
    • Electrolytes
    • U/A
    • CXR
    • EKG
    • Other diagnostic tests including imaging

For each Active Problem

  • Impressions When appropriate give your differential diagnosis
    Include pathophysiology descriptions here when appropriate
  • Plans
    • Diagnostic 
      • List blood tests
      • Radiologic tests
      • Other tests
    • Treatment
      • What medications are you administering for this problem
      • What other modalities are you instituting
  • Potential Discharge Issues