Handoff Communications

Courtesy of Banner Health. Used with permission.

Handoff Communications

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Handoff Communications

Courtesy of Department of Defense Patient Safety Program. Used with permission.

I Introduction Introduce yourself and your role/job (includepatient)

P Patient Name, identifiers, age, sex, location

A Assessment Presenting chief complaint, vital signs and symptoms and diagnosis

S SituationCurrent status, medications, circumstances, including code status, level of (un)certainty, recent changes, response to treatment

S SAFETYConcerns

Critical lab values/reports, socio-economic factors, allergies, alerts (falls, isolation, etc.)

THE

B Background Co-morbidities, previous episodes, past/home medications, family history

A Actions What actions were taken or are required AND provide brief rationale

T Timing Level of urgency and explicit timing, prioritization of actions

O Ownership Who is responsible(nurse/doctor/team) including patient/family responsibilities

N Next What will happen next? Anticipated changes?What is the PLAN? Contingency plans?

Handoffs and Healthcare Transitionswith opportunities to ask

QUESTIONS, CLARIFY and CONFIRM

“““III PPPAAASSSSSS THE BTTHHEE BBAAATOTTOONNN”””

Handoff Communications

Kaiser San Francisco Perioperative Services RN TO RN HANDOFF TOOL (O.R. - PACU / CVICU) DATE _________

************************************************************* SITUATION (patient history):

PATIENT’S AGE & __________________________________________ PRE-OPERATIVE DIAGNOSIS __________________________________________

PERTINENT MEDICAL HISTORY __________________________________________

OPERATIVE PROCEDURE __________________________ (include side and site)

ALLERGIES YES ____________________________________ NKDA SENSORY IMPAIRMENT YES ____________________________________ NO

FAMILY PRESENT ASU WAITING ROOM 5TH FLOOR – CVOR WAITING ROOM

RELIGIOUS/CULTURAL ISSUES YES ___________________________________ NO

ISOLATION PRECAUTIONS YES ___________________________________ NO

INTERPRETER REQUIRED YES ____________________________________ NO VALUABLES / BELONGINGS __________________________________________ (disposition)

INTRAOPERATIVE BACKGROUND:MEDS GIVEN INTRAOPERATIVELY ___________________________________________

BLOOD GIVEN YES NO TRANSFUSED ________ RBCs, _______ PLATELETS _______ FFPS

UNITS AVAILABLE ________

ASSESSMENT OF SKIN INTEGRITY ___________________________________________ (include pressure sites, positioning related areas and incision site)

MUSCULOSKELETAL RESTRICTIONS YES ____________________________________ NO TUBES / DRAINS / CATHETERS _____________________________________ (include size and location) N/A

DRESSINGS / CAST / SPLINT YES ____________________________________ NO COUNT CORRECT YES NO >>> XRAY TAKEN

OTHER (labs, path results, etc) ___________________________________________

PATIENT TRANFERRED TO PACU CVICU

REPORT GIVEN TO ________________ RN >>>> REPORT GIVEN BY ________________ RN (relief only) REPORT GIVEN TO ________________ RN >>>> REPORT GIVEN BY ________________ RN (relief only)

REPORT GIVEN TO ________________ RN >>>> REPORT GIVEN BY ________________ RN

**** NOT PART OF PATIENT CHART****

Patient name and MR #

Courtesy of Kaiser San Francisco. Used with permiss

Handoff CommunicationsSentara Norfolk General Hospital, Norfolk, Virginia 23507

SNGH PACU REPORT WORKSHEET

Form must be filled out completely PATIENT Date:__________________________ Room assigned:__________________________ (Place sticker here) Surgeon:__________________________

PRECAUTION Type Bed: Regular / Telemetry Class I II / Step down / SD Telemetry / ICU Allergies: ______________________ Reaction: ____________________________ Isolation Yes No Type________________________________ Oxygen NC________ FM ______ VENT________________________________ Type of Surgery_______________________________________________________________

Type of Anesthesia: General / Sedation / Local / Spinal / Epidural / Block

Medications given PACU: Versed____ Fentanyl _____ Dilaudid ______Morphine____ Time Last narcotic given_________ Other___________________________ Anitemetic______________ Antibiotic________________________ Time next dose due ______________________ PCA Medication______________Settings__________________Time Started_________ Medical History _________________________________________________________ ______________________________________________________________________PLAN OF CARE Fluids in: OR_______________ PACU_____________ IV fluid /Rate______________________ IV access &location______________________ Output OR_______________ PACU_____________ Foley present Y / N EBL OR_______________ PACU_____________ DRAINS OR_______________ PACU_____________ Number of and location of drains:____________________________________________

DRESSINGS____________________________________________________________ PROBLEMS : Vital Signs: Time: T______HR______ RR______B/P ______Pulse Ox _______Pain Scale____ Review systems (WNL otherwise noted) Neuro/Vascular :_________________________________________________________ Respiratory: ____________________________________________________________ Cardiac/Rhythm: ________________________________________________________ GI / Diet (has patient started ice chips)_______________________________________ GU: ___________________________________________________________________ Musculoskeleton: ________________________________________ Kendalls Y / N Labs __________________________________________________________________ Xrays__________________________________________________________________ Blood Sugar_____________________________________________________________

PURPOSE Time Bed Ready__________________ Time Report Faxed _______________________

Nurse Completing Report__________________________________________________

Time patient arrived to floor______________ On floor bed Y / N

Courtesy of Sentara Norfolk General Hospital. Used with permission.

Handoff Communications

Courtesy of WakeMed Healthcare Health and Hospitals. Used with permission.

Handoff Communications

SBAR Patient Report Guidelines: Perioperative Services

Report given by: Time: __________________ Phone: __________________ Report received by: Phone: __________________

SSituation:

Patient’s name, Age, gender

NPO status (# of hours) Allergies S

Diagnosis/Procedure being performed Advanced Directive, Code status

BBackground:

History / Past hospitalization Infection Control/Isolation Primary Language

Special needs – spiritual, cultural, learning, communication

Religious needs-refuses blood transfusion B Legal status Disposition of Patient belongings

AA

Assessment:Current Status - Preop to OR Current Status - OR RN to OR RN

Planned surgical procedure Current stage of procedure Surgical procedure verified and marked Anesthesia type Planned anesthesia type Allergies Mental status

Position of patient/devices used Allergies Significant medical history

Language barriers Blood products/Consent Blood products/Consent Recent changes in condition Medications received in preop Medications on the sterile field Antibiotics to be given Irrigation fluids in use Blood products available Instrumentation on/off field - needed Significant medical history (Elevated BP, cardiac, asthma, etc.)

Equipment/device needs Implants needed available

Equipment needs (SCD, etc.) Vendor present/needed Catheters/Drains Specimens on and off field Musculoskeletal/Skin: breakdown, casts, wounds, dressings

Drains and catheters Counts o Sponges Surgeon has spoken with patient/family o Needle/Small Items Family waiting/contact information? o Instruments

Communication with family regarding: Clinical/Change in Condition

Current Status - OR Scrub to OR ScrubCurrent Status - OR to PACU/Critical Current stage of procedure CareAnesthesia type Surgical procedure Allergies Allergies Medications on the sterile field Blood products remaining Irrigation fluids in use Drains and catheters Location and count of all countable items currently in use

Motor activity (neuro) Peripheral circulation issue

Instrument trays in use and counts of all instruments

Positional issues Skin integrity

Extra instruments available in room Equipment needs Implants on field/in room Additional issues or concerns Number and location of specimens, on and off the field

Communication with family regarding: Clinical Condition

Any additional issues or concerns Change in Condition

Recommendation:

Courtesy of UCSI Health Sciences. Used with permission

RR Plan for continuing care interventions Abnormal results and related Nursing orders/Nursing plan of care Additional Questions/Comments

_____________________________________________________________________________

Handoff CommunicationsBETH ISRAEL DEACONESS MEDICAL CENTER

NURSING COMMUNICATION SHEET: ICU → OR, OR → ICUTemplate for Verbal Report

ICU → ORPlease call OR when anesthesia takes patient X43000 West X 72411 EastAsk UCO to transfer you to the RN caring for the patient

DemographicsName & Medical Record Number AllergiesBrief history Planned Surgical ProcedurePrecautionsPaperworkNursing Assessment H & PSurgical ConsentAnesthesia consent

Family LocationContact person/number

OR → ICUPlease call ICU 60 minutes prior to anticipated time of transfer

Intraoperative medications/fluids Medications or drips that anesthesia would like available Pumps or other medication delivery equipment needed

Intraoperative issuesRelated to positioningProblems/complications

Special post op needs:LinesIntubated/ventilatedHypothermia equipmentCompression sleevesICP monitoringImplanted devices

Dressings & DrainsType of drain(s)Location of drain(s)Vac dressingAbd open

Courtesy of Beth Israel Deaconess Medical Center. Used with permission.

Handoff Communications

Courtesy of Bloomington Hospital. Used with permission.