Shift change and Patient handoff

Standardized handoff reports
1. Guidelines to follow
  1. Prevents
    1. Treatment delays
    2. Missing information
    3. Knowledge deficits
2. Examples
  1. SBAR
    1. Situation
      1. Name
      2. Unit
      3. Patient
      4. Problem
    2. Background
      1. Admission diagnosis
      2. Pertinent history
      3. Current treatments
    3. Assessment
      1. Current vital signs
      2. Physical assessment
      3. Test results
    4. Requests
      1. Further testing
      2. Transfer
  2. I-PASS
    1. Illness severity
      1. Summary of patient acuity
    2. Patient summary
      1. Patient’s diagnosis and treatment plan
    3. Action list
      1. To-do items
    4. Situation awareness/contingency plan
      1. Directions to follow in event of patient change
    5. Synthesis
      1. Receiver asks questions
Important with handoff
1. ALWAYS document who report was given to
  1. 1. “SBAR report given to…”
      1. Legally shows transfer of care

Therapeutic Management

Handoff issues
1. Without standarized reporting
  1. Linked to adverse events
  2. Breaks in communication
  3. Like the game “telephone”

Nursing Concepts

Clinical judgement
Communication
Safety
Teamwork and Collaboration

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Transcript

Hey guys! Today I want to talk to you a little bit about shift change and patient handoff and the documentation that goes along with this.

So what is patient handoff? So I am sure even if you are a student you can figure out what this is! So at the end of a sometimes horribly long shift we need to let the oncoming nurse know what is going on with the patient they are about to take care of. So in the simplest of words, the patient handoff is a report of information during the transfer of care.

So before I get into the actual documentation portion of this lesson I want to take a second and talk about the goal of the patient handoff. So obviously at shift change giving a thorough report of our patients promotes their safety. However, you may not have ever thought about this process is a team building or coaching and teaching opportunity which it most certainly can be. Guys think about it if you are just starting your shift and you are receiving report from a veteran nurse on your unit this is a perfect opportunity for you to ask questions or even get clarification on things that are still new to you and this is awesome! And someday the roles will be reversed and you will be the one doing the coaching and teaching!

So I can definitely remember how I felt the first time I gave report and I remember being nervous for sure! One of the ways that we can prepare ourselves and prevent that anxiety is by using a standardized handoff report! Guys I have liste 2 examples here being the SBAR or the I-PASS but there are others and your institution may have one of their own so check into to that. If we take a look at the SBAR a little closer this will remind to talk about your patients situation or problem, their background – admission diagnosis, history, treatments, anything to do with their assessment, and finally, the R stands for requests meaning further testing or possible transfer or discharge. The I-PASS stands for I for illness severity, P for patient summary, A for action list, S for situation or contingency plan, and finally S again for synthesis where the nurse receiving the report can ask questions. Guys you will definitely find what works best for you and there are many ways that can work!

Ok so if you take only one thing out of this lesson this would be what I would like to to take away with you! This is so important! Always, always, always document who you gave patient handoff report to. So for example if you use the SBAR, in your documentation whether its in the EMR or on paper you should document “SBAR report given to Sam Jones RN.” Legally you are proving that you have transferred care to the next provider with there being absolutely no lapse in care of the patient.

Lets review! The patient handoff is the report of information during the transfer of care of a patient with included documentation of this handoff. The goal is promote patient safety, team building, coaching/teaching, and always protects the nurse in the transfer of care. Examples of handoff reports are the SBAR or IPASS but there are many others that work just as well. And I will mention this one more time because it is super important….always, always, always documentation that you gave handoff report and who exactly it was given to. ‘

A few nursing concepts that we can apply to the shift change and patient handoff are teamwork and collaboration because we all work together to care for patients, communication which is necessary in patient handoff and finally safety as the purpose of this process is to prevent injury to our patients.

Shift change and Patient handoff

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Outline

Overview

Nursing Points

General

Assessment

Therapeutic Management

Nursing Concepts

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