Verbal Handoff Assessment – Multiple

Hospital or Location*

Other Unit*

Other Provider*

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Verbal Handoff Assessment Tool-Multiple Patients

Indicate the frequency that each element of the mnemonic is present*

I. Illness Severity: Identification as stables, "watcher", or unstable; must occur at the beginning of each patient handoff.

P. Patient Summary: Might include summary statement, events leading up to admission, hospital course, ongoing assessment, plan. A. Action list: To do list; (must be separated from patient summary). S. Situation Awareness/Contingency Planning: Know what’s going on; plan for what might happen. S. Synthesis by Receiver: Written reminder to prompt receiver to summarize what was heard during verbal handoff.

Indicate the frequency with which the provider who gave the handoff did the following.*

	Never	Rarely	Sometimes	Usually	Always
Giver actively engaged with receiver to ensure understanding of patients
Giver appropriately prioritized key information, concerns, or actions
To-do list restricted to items that need to be accomplished on next shift
High quality contingency plans with clear if/than format
Receiver provided a synthesis that summarized the key components of the handoff, rather than restating all information

(eg. encourages questions, asked questions, considers learning style of receiver)

Did you provide verbal feedback to the handoff team?*

Yes	No

Share one REINFORCING piece of feedback based on your handoff observation. For HIPAA compliance, patient-specific information should NOT be entered in to this form.

Share one CORRECTIVE piece of feedback based on your handoff observation. For HIPAA compliance, patient-specific information should NOT be entered in to this form.

Hospital / Organization*

Technical Support

Verbal Handoff Assessment – Multiple

For questions on the appropriate form to use, contact your implementation team or I-PASS Program Manager.

Verbal Handoff Assessment (MULTIPLE patients)

Verbal Handoff Assessment Tool-Multiple Patients