Handoff Communications
Courtesy of Banner Health. Used with permission.
Handoff Communications
Cou
rtsey
of P
arkw
est M
edic
al C
ente
r. U
sed
with
per
mis
sion
.
SPa
tient
ID L
abel
Her
eSu
rgeo
n:
Proc
edur
e:
NPO
Sta
tus:
H
t/Wt:
Site
Mar
ked:
Proc
edur
e:
Ane
sthe
sia
Typ
e: G
ener
al –
Epi
dura
l – S
pina
l – L
ocal
– M
AC
O
ther
:
His
tory
: (ci
rcle
)
O
ther
:N
euro
– S
eizu
res -
DM
– C
ardi
ac D
z –
Dys
rhyt
hmia
– H
TN –
Res
p D
z –
Ast
hma
– R
enal
Dz
– Li
ver D
z –
Mal
igna
nt H
yper
ther
mia
Alle
rgie
s:
Isol
atio
n (c
ircl
e)
MR
SA –
VR
E –
TB -
O
ther
: C
ultu
ral/I
nter
pret
er:
/
Per
sona
l Bel
ongi
ngs:
____
____
____
____
____
____
__ G
iven
to:_
____
____
____
____
____
____
___
B
Fam
ily C
onta
ct In
fo:
Loc
atio
n: W
aitin
g R
oom
– U
nava
ilabl
e
Con
tact
#:
ASU
PSA
OR
PA
CU
/ASU
/CC
U
T/H
R/B
P/R
R/S
aO2:
Skin
: N
euro
: Pu
lmon
ary:
C
ardi
o/R
hyth
m/P
V:
Gas
troIn
test
inal
: G
U/C
ath/
Dra
ins:
C
ircle
: Fo
ley
– C
BI -
JPx
___-
Hm
vac
– O
ther
: D
ress
ings
: M
uscu
losk
elet
al:
Pain
: Ep
idur
al/B
lock
: IV
Site
& IV
F LT
C:
Site
:
L
TC:
Site
:
LTC
: Si
te:
LT
C:
Line
s (C
VL,
A-L
ine)
: In
take
/Out
put &
EB
L:
I=
O=
I=
O=
I=
O=
E
BL:
M
eds/
Rev
ersa
l Giv
en:
Infu
sion
s:
Blo
od G
iven
/Nee
ded:
G
iven
:
N
eeds
: G
iven
:
N
eeds
:
A
Abn
Lab
s & L
ast B
S:
BS=
BS=
B
S=
Bet
aBlo
cker
Pro
toco
l: Y
es
N
o
N/A
Y
es
N
o
N/A
Y
es
N
o
N/A
D
VT
Prot
ocol
: Y
es
N
o
N/A
Y
es
N
o
N/A
Y
es
N
o
N/A
O
ther
: Sp
ecia
l Equ
ipm
ent:
Acu
te O
rder
s:
Une
xpec
ted
Even
ts:
Post
Op
Des
tinat
ion:
A
SU
C
CU
Flo
or
ASU
CC
U
F
loor
A
SU#_
____
__
C
CU
#__
____
_
Flo
or R
oom
#__
____
__
R
Med
s (A
ntib
x) n
eede
d
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.
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