Verbal Handoff Assessment – Single

Hospital or Location*

Department or Service*

Other Department or Service*

Unit or Care Area - [Hospital 1]*

Unit or Care Area - [Hospital 2]*

Unit or Care Area - [Hospital 3]*

Other Provider*

Other*

Verbal Handoff Assessment Tool-Single

Indicate whether or not each element of the mnemonic is present*

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 following elements were present in the observed handoff:*

	No	Yes
Giver actively engaged with receiver to ensure understanding of patients
Giver appropriately prioritized key information, concerns, or actions
Provided to-do list restricted to items that need to be accomplished on next shift
Used high quality contingency plans with clear if/then format
Receiver provided a synthesis that summarized the key components of the handoff, rather than restating all information

Did you provide verbal feedback to the handoff team?*

Yes	No

Share one REINFORCING piece of feedback based on your handoff observation

Share one CORRECTIVE piece of feedback based on your handoff observation

Technical Support

Verbal Handoff Assessment – Single

Verbal Handoff Assessment (SINGLE patient)

Verbal Handoff Assessment Tool-Single