Content | |
Patient presentation |
Patient identifiers | Statements that convey patient identifiers such as name, date of birth or hospital number. |
Clinical history | The patient's past medical problems/conditions that are pertinent to the current diagnosis or clinical impression. |
Social history | The patient's social circumstances and psychological needs describing, for example, housing situation and existing care arrangements, family or friends accompanying, etc. |
Symptom | Descriptions and explanations that provide information about symptoms of concern. |
Procedure | Statements about pertinent laboratory data, pertinent test results, medications and evaluation that already been performed to address the patient's current condition. |
Assessment |
Treatment | Statements about future medical procedures to be taken to address the patient's current problem. |
Clinical impression | Identification of the current clinical impression, naming the problem or reasons for the problem. |
Prognosis | Probabilistic statement about patient's future condition based on completed or proposed treatments. |
Outcome | Definite utterances about the result of the handover, for example, accept, not accept, wait and see. |
Transfer of responsibility | Statements about what was being asked of the recipient of the handover. |
Professional environment |
Logistic processes | Descriptive or evaluative talk about logistics or procedural issues in emergency department, hospital, or healthcare system. |
Courtesies | Statements such as thank you, greeting and closing remarks, etc., that provide a context of professional courtesy. |
Language form | |
Information seeking |
Closed question | An utterance that is designed to solicit specific information. |
Open question | An utterance that is designed to solicit information in a manner that affords the respondent the opportunity to elaborate. |
Clarifying question/request | An utterance that is a question designed to seek clarification of another's immediately preceding utterance. May take the form of a request. |
Information giving |
Description | Utterances that provide description about the patient and the patient's past or present condition and circumstances. |
Explanation | Utterances that state the facts and make an inference about the patient. |
Rationale | A justification is offered to account for any medical procedures, tests, medications or recommendations concerning the patient. The intent is to justify why an action has been taken or will be taken in the future. |
Directive | Advisements, orders or recommendations that inform patient evaluation, treatment and disposition. |
Context talk | Talk about contextual issues in clinical environment such as logistics and procedures. |
Social amenities | Utterances in which physicians exchange courtesies and talk that tells the sender that the receiver is paying attention. |
Decision | Utterances in which the physician accepts or does not accept the patient. May be directly stated or implied. |
Information verifying |
Read-back | Statements that paraphrase or restate what the other has said. |