Written Handoff Assessment - Multiple

Unit or Service*

Other Unit

Provider Type of Individual Giving Handoff*

Nurse
Advanced Nurse Practitioner
Physician Assistant
Resident Physician
Physician Fellow
Attending Physician
Other

Other Provider

Day of Week*

Weekday
Weekend

Time of Day*

AM
PM

Written 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	Unable to evaluate
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/then format

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

Observer Name*

First Last

Technical Support

Written Handoff Assessment – Multiple

Written Handoff Assessment (Multiple patients)

Written Handoff Assessment Tool-Multiple Patients