Transfer of Care Documentation for Certified Perioperative Nurse (CNOR)

Transfer of Care Documentation

Guidelines:

• Interdisciplinary communication in the OR is essential for efficient, effective, and successful patient care
• Communication includes:
  • Documentation
    • Communication of the activities that took place in the OR
    • Also includes critical information about patient and procedure
    • Allows for continuity of care
  • Transfer of Care/Handover Communication
    • A process and documentation form
    • Written and verbal communication
    • Should be standardized and simplified transfer/handover processes for error prevention
    • Cognitive aids and checklists should be used to remember key tasks and safety information and improve flow of
      communication among team members
      • SBAR, IPASS, PEARLS, etc.
    • Transfer of care process, communication, and documentation per facility policy

Considerations:

• The patient is more vulnerable to the incidence of error in the surgical setting than in other settings because of the multiple hand over events that occur throughout the preoperative, intraoperative, and postoperative phases of care
• Interesting facts:
  • Individuals can only maintain an average of seven facts in their working memory at any one time
  • Short-term memory limits an individual’s ability to recall a list of critical tasks
  • Use of cognitive aids and checklists helps perioperative nurses avoid forgetting essential process steps.

Nurse’s role:

• The successful and safe transfer of the patient during all phases of care is contingent on optimal communication.
• The perioperative nurse should:
  • Use communication tools during care transfers
  • Convey vital patient information to the nurse receiving the patient
  • Provide patient information via written and verbal communication
  • Standardized communication format delivered in a face-to-face exchange

Pitfalls:

• The surgical team is responsible for the patient’s safe journey through the surgical care continuum because the patient is often unable to alert the team if there is misinformation, which makes efforts to prevent mistakes crucial.
  • The Joint Commission: Communication breakdowns are a common root cause of sentinel events.
  • An adverse event may therefore occur because of competing priorities and inappropriate system processes rather than
    one specific team member’s actions
  • Organizations should have standardized processes and tools in place to promote patient safety, especially during handovers where there is a high risk for errors

Examples:

• SBAR Technique to facilitate transfer of pertinent information from one team member to another during a patient hand over.
• Situation
  • Describe patient’s status
• Background
  • Clinical background
• Assessment and Evaluation
  • A/E of current issue necessitating the hand over
• Recommendations
  • Recommendations for subsequent care
• Perioperative RNs can use SBAR to standardize critical communication among team members in the perioperative environment.
• Gather and relay information consistently, engage in critical thinking, and work together to proactively identify ways to provide safe patient care

Linchpins (Key Points):

• Transfers of care should include verbal and written communication
• Transfers of care should be face-to-face with receiving nurse
• Transfers of care should include the opportunity for questions and clarification from receiving team member
• Transfers of care are a vulnerable time for patient safety events. The perioperative nurse plays a vital role in ensuring safe
  patient handover.