Date
of Last Review: 3/16/2012
SME: Medical Director, Social Services Director, Director of Patient Services & Chief Nursing Officer
| Purpose | To insure safe hand off communication between team members for all patients. |
| Definition: | A hand off at UTHCPC includes, but is not limited to Nursing shift change
|
Hand off communication includes up-to-date information regarding the patient's treatment, condition and any recent or anticipated changes
Interruptions are to be minimized during hand off.
Hand off communication requires a process for verification of the received information, and may include repeat-back or read-back of the information conveyed.
The receiver of the hand off information has the opportunity to review relevant patient historical data, which may include previous treatment or services.
Department Specific Guidelines
NURSING
Nursing Shift Report:
Oncoming and off going staff are to attend shift report, followed by a period of time to allow for questions and answers.
Nursing staff will complete hand off if information for assigned patients when leaving the unit for any reason and/or when taking a break on the unit. Information is to be shared when the staff returns to the unit as well
Nurse to Physician Report
Nursing Staff will reference the SBAR communication form when communicating with the physician.
SBAR is an acronym for:
Situation – State what is happening at the present time that has warranted the SBAR communication.
Background – Explain Circumstances leading up to this situation.
Assessment – What do you think the problem is?
Recommendation – What would you do to correct the problem?
In addition, the nurse will report critical information from the previous 24 hours to the physician at morning rounds each day. This may include:
The nurse will document any notification of critical information to the physician in the progress notes.
PT. REGISTRATION:
New admission information exchange:
Verbal report is given to unit RN before patient goes to unit
SOCIAL SERVICES:
Off unit group:
Social service staff asks RN for status report on patients before escorting
to off unit groups
Social service clinician reports any significant observations to unit staff
upon return/
following group and is available for exchange of information at that time.
Case manager to case manager:
It is expected that Sr. Case managers will be knowledgeable of sufficient clinical
information to provide continuity. Social service clinicians are available 24hr/
7days/ week for clinical issues
Hand off communication is expected for vacation coverage.
MEDICAL STAFF
For Planned Absences:
Physicians will provide a hand off document, either on paper or by email, to
the covering
physician. The document will contain pertinent information about current treatment
and
condition as well as about any recent or anticipated changes. The information
will be provided within a timeframe sufficient for the receiving physician to
review the information and request any additional information needed. A similar
document will be provided by the covering physician on the return of the physician
taking leave. Documentation that this exchange occurred will be included in the physician progress note.
For the On-Call Period:
Physicians will notify the on call house officer of any patient that is anticipated
to require monitoring or intervention during the on-call period prior to the
on-call coverage period. The house officer will be paged and the information
discussed verbally. Additionally, the physician may request by entering an order
that certain events or information, such as lab values, be communicated to the
house officer in the on-call period. At the end of the call period, the on-call house officer will notify the receiving team or on-call physician or patients with urgent clinical isues.
For Transfer to Another Hospital:
The process for completion of a Memorandum of Transfer defines expected communication
between UTHCPC physician and receiving physician.
Related Standards:
The Joint Commission: Provision of Care, Treatment, and Services
Medicare Condition of Participation for Psychiatric Hospitals
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
