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Verbal Handoff Assessment – Single

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Verbal Handoff Assessment – SingleChristina2017-03-02T15:41:09+00:00

Verbal Handoff Assessment (SINGLE patient)

"*" indicates required fields

Provider Type of Individual Giving Handoff*
Day of Week*
Time of Day*
Where Did the Handoff Occur?

Verbal Handoff Assessment Tool-Single

NoYes
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.
NoYes
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
YesNo
Observer Name*
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