Table 1.

Changes made to written sign-out after implementation

Problem identified	Solution	Impact	Remaining challenge
Unclear when sign-out last updated	Date/time stamp added to printed sign-out report for each sign-out note	Percent of notes updated same day as of 7pm:* Gynecology: 50% Medicine: 89% Obstetrics: 90% Pediatrics: 83% Surgery: 70% Last updated more than 1 day prior to audit: Gynecology: 29% Medicine: 2% Obstetrics: 3% Pediatrics: 6% Surgery: 8%	Which fields updated not apparent Continued use of relative time words such as “yesterday,” “tomorrow”
Out of date task lists	Date/time stamp added to each to do item	Percent of notes using “to do” section:* Medicine: 51% Surgery: 14% Pediatrics, obstetrics and gynecology: 0% Proportion of tasks ≤1 day old:* Medicine: 82% Surgery: 0%	“To do” section not used consistently across specialties Tasks inconsistently updated
Desire for specific laboratory results by surgeons	Hgb, Hct, PT, PTT, Ca, ionized Ca, WBC, bilirubin, cyclosporin level, tacrolimus level automatically inserted into surgery sign-out notes	Not assessed
Creating sign-out note time consuming	Ability to import progress note data into sign-out note	Proportion of notes linked to progress note:* Medicine: 46% Surgery: 14% Pediatrics: 43% Ob/gyn: 22%	Purpose and format of progress note not aligned with sign-out note, limiting utility of this option
Proper paperwork not completed for discharge	Nursing agency paperwork flag added to sign-out notes	Not assessed
Difficulty identifying patients likely to be discharged	“Likely discharge” field added to sign-out note, with date/time stamp	Year to date 2011 (tracked by service line and including updates from progress notes): Surgery 72% Medicine 85.5% Oncology 51.9% Psych 81.6% Pediatrics 73% Heart and Vascular 89.4%	Lack of consistent update impaired patient identification; likely discharge field added to progress note as well to improve utilization
Patients in care of conservator inappropriately managed without involvement of conservator	Automatic conservator indicator added to sign-out note	Not assessed
Patients admitted to observation status often not documented appropriately	Observation status flag added to printed sign-out report	Not assessed

^*Data from 2012 audit of 514 charts, 456 sign-out notes

^**Data from 2011 audit of 88 charts, 74 sign-out notes