Change-of-Shift: Hand-off Report
Category: Communication
Status: Stub — content coming soon
Purpose
Hand-off communication transfers responsibility and accountability for patient care between nurses. It is a high-risk moment — incomplete hand-off is a leading cause of sentinel events.
SBAR Format
| Element | Content |
|---|---|
| Situation | Patient name, age, room, diagnosis, reason for admission |
| Background | PMH, relevant history, code status, allergies |
| Assessment | Current status, recent changes, vital signs, labs |
| Recommendation | Pending tasks, what to watch for, upcoming procedures |
I-PASS Framework (expanded)
| Element | Meaning |
|---|---|
| Illness severity | Stable / watcher / unstable |
| Patient summary | Diagnosis, events, plan |
| Action list | To-do items for next shift |
| Situation awareness | Contingency planning (“If X happens, then…”) |
| Synthesis by receiver | Read-back / opportunity to ask questions |
Key Elements to Include
- Current vital signs and trends
- Active problems and nursing diagnoses
- Lines, tubes, drains (insertion date, condition)
- Medications due next shift (especially high-alert)
- Diet, activity, isolation status
- Pending labs, imaging, procedures
- Patient/family concerns or teaching needs
- Safety concerns (fall risk, restraints, allergies)
Documentation
Describe bedside hand-off expectations and EHR note requirements.
Notes
Add personal notes here.