A content analysis of documentation on communication disability in hospital progress notes: diagnosis, function, and patient safety

OBJECTIVE:: To examine the content, quantity, and quality of multidisciplinary team documentation of 'communication' in hospital progress notes of patients with communication disability, and to explore the relationship of this documentation to patient safety. DESIGN:: Retrospective chart review involving a descriptive analysis and a qualitative content analysis of the progress notes. SETTING:: Acute medical and rehabilitation wards in two regional hospitals in one health district in Australia. PARTICIPANTS:: Eight patients with communication disability who had experienced documented patient safety incidents in hospital. METHODS:: In total, 906 progress note entries about communication during 38 hospital admissions were extracted from eight patient's charts; written by staff in 11 different health disciplines. Data were analysed descriptively according to quantity, and qualitatively according to the content. RESULTS:: Four content categories of meaning in progress note entries relating to communication were (1) use of communication diagnostic and impairment terms; (2) notes on the patient's communicative function; (3) reports of the topic or content of the patient's communication attempts; and (4) references to third parties communicating for the patient. Communication-related information was often brief, unclear, and/or inaccurate. Descriptions of communicative function and recommended strategies for successful communication were often lacking. CONCLUSION:: The suboptimal documentation of patient communication in progress notes may contribute to the higher risk of patient safety incidents for hospital patients with communication disability. Increased accuracy in documenting communication disability and function in progress notes might assist staff in communicating with these patients and improve the quality and safety of their care.