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Written Handoff Assessment – Single
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Written Handoff Assessment – Single
Written Handoff Assessment – Single
2017-07-25T18:20:25+00:00
Written Handoff Assessment (SINGLE patient)
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" indicates required fields
Location
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Central Medical Center
South Medical Center
Unit - Central #1
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ED
General Surgery
ICU
PACU
L&D
Other
Unit - South
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Cardiology
Emergency Department
ICU
Internal Medicine
NICU
OB / GYN
Oncology
Pediatrics
Surgery
Other
Other Unit
Provider Type of Individual Giving Handoff
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Nurse
Attending Physician
Physician Fellow
Resident Physician
Nurse Practitioner
Multiple/Inpatient Night Rounding
Other
Other Provider
Day of Week
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Weekday
Weekend
Time of Day
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AM
PM
Written Handoff Assessment Tool: Single
Indicate whether or not each element of the mnemonic is present
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No
Yes
I. Illness Severity
P. Patient Summary
A. Action List
S. Situation Awareness/Contingency Planning
S. Synthesis by Receiver
I. Illness Severity: Identification as Stable, 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 whether or not the provider who gave the handoff did the following.
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No
Yes
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
Do you have another handoff to enter?
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Yes
No
Did you provide verbal feedback to the handoff team?
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Yes
No
Rate the overall quality of the following:
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Unable to Evaluate
Does NOT yet meet high standard
Meets high standard
Patient Summary
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.
Observer Name
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First
Last
